Running up a flight of stairs, you feel your heart “pounding.” The awareness that your heart is beating is referred to as “having palpitations.” The hard, fast breathing has a regular rhythm because it is caused by the normal action of our natural pacemaker, the sinus node. The increased pace of the heart is simply a response to the increased needs of your body.
This palpitation symptom is not abnormal; that is, it is not caused by an arrhythmia (abnormal heart rhythm). It is called sinus tachycardia (pronounced “tak”ee-kar’dee-ah”), which means a fast heart rate, usually above 100 beats per minute. The SA node has responded to the body’s need for more blood and oxygen by increasing the number of impulses it generates per minute. The heart simply beats more quickly in response to it and gets more oxygen circulating to the parts of the body in need.
Common causes of a rapid heart rate (sinus tachycardia)
Lying in bed, you notice your heart beat. It seems it is beating very slowly at 45 to 50 beats a minute. Is it normal to have such a slow heart rate? In fact, it’s quite normal when the body is at rest and the need for circulating blood and oxygen is at a minimum.
The regular, slow rate you’re able to feel is called sinus bradycardia (pronounced “brad”ee-kar’dee-ah”), which means a slow heart rate. The SA node has responded to the body’s reduced needs by initiating fewer impulses per minute. The heart is simply beating less frequently in response to the reduced rate of the natural pacemaker.
Common causes of a slow heart rate (sinus bradycardia)
Rest and relaxation (“dozing,” sleeping, lying down)
Good physical conditioning (frequent, regular exercise)
High blood pressure medications such as calcium channel blockers, beta blockers or clonidine
Some of these medications may be used to treat angina, (chest pain), which is caused by poor blood flow to the heart muscle itself.
Certain eye drops for glaucoma can rarely be absorbed and in some individuals, slow the heart rate.
A “varying heart”
A normal fluctuation of the heart rate occurs with changes in breathing and is generally so slight as not to be noticed, except in some individuals. It is called sinus arrhythmia. As we breathe in, our heart rate quickens just a little. When we breathe out, our heart rate slows.
You can observe this yourself by resting quietly with your finger on your pulse. Note that your pulse rate quickens when you take a sudden, deep breath. This is a normal response that is mistakenly called arrhythmia because in some patients, especially children, the changes are more than expected and appear almost as a true irregularity. You can be sure this is a “normal arrhythmia” and never requires concern or treatment.
It’s easiest to “find the pulse” where arteries are closest to the skin surface - neck, wrist, groin and ankles.
Step-by-step: From symptoms to diagnosis
Understanding the visit to the doctor
As a person troubled by a symptom and possibly anxious concerning what lies ahead, you may find it helpful to know the approach your doctor will take to arrive at an accurate diagnosis and treatment appropriate for you.
The doctor’s goal is to find out if any heart disease is truly present and to do so in the least difficult manner. The medical history is the first step, usually completed through a discussion with the patient that gives the doctor an understanding of the major problem. This is usually supplemented by a written questionnaire that asks for background information about the patient’s health, including details about previous health problems, hospitalizations, operations, medications, allergies, and cardiac risk factors such as high blood pressure and cholesterol levels, smoking, diabetes and family history.
The physical examination
The physical examination is performed next in an effort to find any abnormalities that could indicate the existence of a heart problem. The examination may be limited to the heart and circulatory system (cardiovascular system) if the problem is solely arrhythmia. However, since other health problems can cause arrhythmias, a complete physical examination may be performed and general medical problems may be reviewed. The search for signs of heart disease includes an evaluation of blood pressure, heart rate and rhythm. The condition of the neck veins and arteries as well as the blood vessels in the back of the eye are assessed; and the lungs, heart, abdomen and extremities are evaluated as well.
By listening to the chest for breath sounds, the physician can determine if there is fluid in the lungs (a sign of heart weakness or failure). Listening to the heart can provide not only information about the rate and rhythm of the heart, but also whether a mechanical problem exists with the heart’s pumping action. If a heart valve problem is present, such as a blocked or leaking valve, the flow of blood through the heart may be disturbed, causing heart murmurs that can be heard.
The sound of a murmur is much like the sound of water running through a kinked garden hose. Often, even the normal flow of blood will produce a sound loud enough to be called a murmur (especially in thin people or children). Therefore, detection of a heart murmur alone does not necessarily mean there is a problem with the heart or any of its valves. More information will be needed before it can be labeled a problem.
The next step is to schedule one or more routine non-invasive tests designed to identify heart problems with a minimum of risk, inconvenience and discomfort to the patient. When the problem is palpitations, the four most common and informative tests are likely to be the EKG, or ECG (electrocardiogram), exercise stress test, 24-hour Holter (ambulatory ECG) recording, and echocardiogram. These are described later in this manual.
After the history, physical exam and initial testing are completed, the physician will review the results and determine the proper follow-up or treatment. It may be that the diagnosis is definite and no treatment at all is necessary. On the other hand, the diagnosis may still be unknown and require additional testing. If the evaluation is done by your regular doctor (primary care doctor, family doctor or generalist), a consultation with a cardiologist (heart specialist) may be considered. If the evaluation has been done by a specialist at the request of your regular doctor, a report will be sent to your doctor summarizing the findings and recommendations. A cardiologist and primary care physician will generally work together if ongoing consultation is needed.
If follow-up testing or treatment is recommended, you can help your doctor care for you by “joining the team” and actively assisting in your own care. Here are a few simple ways to help:
Follow instructions carefully.
Be sure to have questions about treatment clarified (write the answers down, or, if you are still doubt, ask for them in writing).
Know each medication you are taking and its dosage.
Keep regular follow-up appointments.
Report problems in getting or taking your medications.
Be a careful observer, reporting relief of symptoms with treatment as well as any new problems that may appear.
Learn as much as you can about your problem and its treatment, but don’t diagnose yourself-that’s the doctor’s responsibility.
(Looking for sings of heart or blood vessel disease)
PATIENT REVIEW AND RECOMMENDATIONS
*Treatment (if indicated)
*Follow-up (office visits and additional testing, if indicated)
Abnormal heart rhythms- How you might feel
Awareness of the heart’s beating (palpitations)
Abnormal heart rhythms (arrhythmia) might be reported by different individuals as “palpitations,” “skipped beats,” “extra beats” or “heart fluttering.” Some have called it:
“flip-flopping inside my chest”
“a little tickle, that makes me want to cough”
“a sudden strong and hard beat”
“a throbbing in my neck”
“a nervous (jittery) feeling inside”
“like a car with a rough idle”
“a feeling of anxiety”
“like my heart is stopped”
It’s difficult to describe a sensation coming from inside the chest with ominous implications. The anxiety and stress can often reduce our ability to observe and think clearly.
During an arrhythmia, patients have reported watching their neck veins “quiver” or “jump up and down.” Others report seeing the front of their chest wall move, just under the left nipple. This is where the heart touches the inside of the chest wall. Try to detect your heart’s motion by lying quietly on your left side with your right hand under your left nipple. Can you feel it? It’s easy to understand how this might be worrisome if the heart beat is very fast, slow or irregular.
Effects of abnormal rate and rhythm on the circulation
Lightheadedness is a symptom that may result from a temporary drop in blood pressure and may be caused by an arrhythmia if the heart’s pumping capacity is sufficiently disturbed. Sometimes referred to as “fainting,” “giddiness” or “dizziness,” the symptom is similar to the sensation you feel when you “stand up too fast.” You think you’re going to faint, but you don’t.
Fainting (syncope, pronounced “sin’ko-pee) is a severe form of lightheadedness that is generally the result of inadequate circulation of blood to the brain. It can result from a severe drop in the heart’s pumping capacity, caused by an arrhythmia that is either too fast or too slow, that results in a significant fall in blood pressure. This symptom is very important to relate to your doctor.
Chest discomfort (pressure, tightness or pain) may be caused by an irregular heart rhythm. The discomfort may belt in the neck, jaw, back, shoulders or arms, or may spread to these places. It may result from the high workload placed on the heart by a very rapid heart rate or be caused by too little blood flow through a diseased artery that supplies the heart muscle with blood and oxygen. In either case, the pain results from too little oxygen to the heart muscle.
Shortness of breath may result from an arrhythmia that sufficiently reduces the heart’s ability to pump blood. If the heart rate is too slow there may be too few beats to circulate enough blood. On the other hand, a very fast heart rate may cause the heart muscle to contract so rapidly that it cannot fill properly, or the walls become weak, causing an ineffective squeeze.
Increased sweating may occur during abnormal rhythms, especially if they cause a sluggish circulation, low blood pressure or chest pain (angina).
Increased urination may be produced by certain fast heart rhythms (tachycardias). It may be the result of a hormone released by the heart muscle and acting on the kidneys, causing them to make extra urine.