When Heart Palpitations Become a Problem
She knew it wasn't normal. For two years, Leah would have heart fluttering -- to the point where you could see her chest moving vigorously -- with no clear inciting event or warning. These symptoms commonly occurred during volleyball and therefore restricted her ability to compete effectively. Fearing something was wrong, she sought advice from physicians, both of which thought "it was in her head." Going with her instinct, she sought another opinion, which led her to my office. I met Leah about one year ago, and it was clear to both of us that her heart rhythm was abnormal.
The Cause of an Off-Tempo Heart Beat
The term "palpitation" refers to the sensation that the heart beat is faster than normal. Although some palpitations are considered benign, a carefully-taken patient history typically exposes important clues that an abnormal heart rhythm, or arrhythmia, might be the culprit. Palpitations that have a rapid onset and offset serve as an important clue that an arrhythmia is occurring. This is exactly what Leah described, and thanks to her very clear explanation of symptoms, I knew not to ignore her.
Much like an orchestra maestro synchronizes complex sounds into symphony, electrical signals in the heart synchronize muscle contractions resulting in heart beats. In order for the heart to function effectively and efficiently, the electrical system has to perform in a regulated fashion. As such, the electrical system runs on the equivalent of railroad tracks -- a very specialized tissue that allows for efficient electrical conduction. Patients with arrhythmias often have extra electrical connections, and arrhythmias can occur when the electrical system uses these accessory connections. Instead of the heart beating at a normal rate, these extra electrical connections can cause the heart rate to abruptly race at rates which exceed the normal capacity of the heart. When this occurs, patients will sense a rapid and uncomfortable increase in their heart rate referred to as palpitations.
Pulse Problem-Solving
Not all palpitations are considered abnormal. It's common for the heart to skip for single beats, causing an unusual sensation. With rare exception, these single-skipped beats are considered normal. In contrast, a patient who experiences an abrupt change in heart rate -- like Leah -- requires further investigation. Palpitations in these scenarios can often be accompanied by discomfort, chest pain, dizziness or even passing-out spells. These important clues serve as red flags that the patient's palpitations represent an arrhythmia, and further evaluation is warranted.
During an evaluation, your physician will obtain a detailed history with particular attention to symptoms such as discomfort, chest pain, dizziness and fainting. An electrocardiogram -- a non-invasive study that assesses the electrical conduction of the heart in its resting state -- will likely be performed during the initial evaluation. Occasionally, even at rest, the ECG can show subtle clues that an extra electrical connection exists. If the ECG is normal and the details of the history suggest an arrhythmia, ambulatory monitoring may be employed. Ambulatory monitors are wearable devices that serve to capture the electrical activity in the heart during an episode. Your doctor will instruct you to record any symptomatic events with your device. This strategy provides a definitive diagnosis if an arrhythmia is in fact captured.
Irregular Palpitation Prognosis and Treatment
Depending on the underlying electrical problem, the prognosis and treatment of arrhythmias can vary. Most often, arrhythmias that occur in otherwise healthy children (like Leah) are referred to as supraventricular tachycardia. The prognosis for SVT is excellent and luckily, SVT is not considered a life-threatening condition. Management for SVT is largely predicated on symptoms but can include observation, medical therapy or catheter ablation. Catheter ablation involves a procedure in which an electrophysiology doctor will use electrical wires placed inside the heart through the groin. These wires provide a map of the patient's electrical system and can identify accessory electrical connections. Typically, once the accessory tissue is identified, a special catheter called an ablation catheter can be used to deliver energy to the accessory tissue and destroy the electrical activity in that small area. Catheter ablation for SVT is considered quite safe and has outstanding success rates.
Working on our suspicion, we prescribed a monitor for Leah and quickly captured her arrhythmia, which turned out to be SVT. After a careful discussion of treatment options with Leah and her family, she chose to undergo a catheter ablation. The procedure was extremely successful, and I'm happy to report Leah's symptoms are now gone. This active, volleyball-loving teenager is living proof that with the right prognosis and treatment, patients with arrhythmias are able to get their heart beat back on track and live normal, healthy lives.
Dr. Peter Aziz completed his pediatric cardiology fellowship at the Children's Hospital of Philadelphia in 2010 and continued his training there in pediatric electrophysiology. During his fellowship, Dr. Aziz was awarded a training grant under the National Institute of Health (NIH) to investigate genotype and phenotype correlations in pediatric patients with long QT syndrome. Dr. Aziz also acquired skills in catheter ablation of pediatric arrhythmias and device (pacemaker and ICD) implantation. Following his fellowship, Dr. Aziz joined Cleveland Clinic Children's as a pediatric electrophysiologist. He is active in the training and teaching of medical students, residents and fellows, an activity that continuously inspires him. Dr. Aziz is also quite active in research and was the recent recipient of the SADS 2011 Young Investigator Award for his work on long QT syndrome. Dr. Aziz acquired skills in Catheter Ablation of pediatric arrhythmias and device implantation, which is a regular part of his clinical practice. Connect with him on Twitter at @PeterAzizMD.
