A lot of my work involves talking to and reassuring people who suffer from ectopic heart beats which seem to cause a great deal of anxiety and really seem to have a negative impact on quality of life.
Most patients I have spoken to have already seen a doctor for their symptoms of ectopic beats and the doctor has told them that they are not dangerous but for many this reassurance is seldom enough.
The anxious mind needs more than that cursory reassuring pat on the shoulder. Part of the reason I think is that when ectopic beats are felt they are uncomfortable and scary and the anxious mind starts asking all sorts of questions – some rational and others irrational. The poor patient goes looking for answers and eventually ends up scouring the internet and ending up even more confused and terrified. In this blog, I wanted to help reassure patients by helping them ask and answer some rational question about ectopic heart beats.
If we think rationally, ectopic heart beats are only really important for 2 reasons:
1) They may be a sign of something wrong with the heart and therefore they may represent some sort of warning that something bad may happen in the future – so a useful analogy would be that ectopic beats are like baby snakes and you are worried that there may be a mother snake waiting to bite nearby
2) The ectopic beats in themselves are causing the heart and the patient some form of damage – ok so there is no mother snake nearby but could the baby snakes bite?
Lets try and answer these two questions:
1) Could they be a sign of something wrong with the heart?
To answer this, it is important to do some kind of tests to study the heart.
The first and easiest test is always a 12 lead ECG. This is done because it is very readily available and gives us a graphic representation of the way the electricity is being conducted through the heart at rest. If the heart is damaged, the passage of electricity through it is often affected and this is easily seen on an ECG. A completely normal 12 lead ECG makes it very unlikely that the heart is in someway structurally abnormal or damaged.
The second test is to do some kind of prolonged heart rhythm monitoring to ‘capture’ the symptoms. i.e when the patient has his typical symptoms what is his heart rhythm? If the ECG is normal during the symptoms, then one can be certain that the symptoms are not cardiac to start with. It is very important to capture the symptoms and therefore the duration of monitoring has to be decided on the basis of how frequent the patients symptoms are. So a 24 holter monitor is only useful if the symptoms are happening daily. More often than not, in my experience, a holter will rarely capture typical symptoms and therefore I prefer either 7 day or 14 day monitors. These monitors aim to capture every single heart beat for the duration of the recording and therefore the battery life means that they can only be used for upto 1 month at most.
If the symptoms occur less frequently then one can use event recorders which will only record when a button is pressed and finally the gold standard is a REVEAL device which can be implanted under the chest wall and can stay with the patient for upto 2 years.
The third test is an echocardiogram – an ultrasound based assessment of the heart. This is even better than an ECG because it allows us to visualise the heart and see it moving. We can assess the valves and even estimate how well the heart pumps. A normal echocardiogram is always incredibly reassuring. The one thing an echocardiogram does not give information about is the state of the blood vessels that supply the heart. For this, a stress test is a much more useful test.
The final test is a stress test. This gives us useful information about the blood vessels that supply the heart with blood as well as gives both the patient and the doctor a lot of confidence that the patient can put his heart through stress without coming to harm. If there is something wrong with the heart it is far more likely to show up at time of stress./exercise and this is why normal stress test is again hugely reassuring. We also know that patients who manage more than 9 minutes on the Bruce Protocol on the treadmill are by definition.
Could the heart still be diseased even if these tests were completely normal. Yes, but it would be very very unlikely. Occasionally people may have inherited some form of genetic predisposition which may not manifest as an obvious structural change detectable on the tests we do. This is why we ask about family history. If there is no family history of premature sudden cardiac death below the age of 40 then again this is a reassuring sign and makes it unlikely that a person may have inherited a genetic predisposition.
Finally, there is perhaps the best test of all and that is the test of time. I often speak to patients who say that they have suffered from ectopics for 20-30 years and are still terrified by them. I always say to them if no mother snake has shown up in 20 years then you can be pretty sure that there is no mother snake around.
2) The second question to answer is ‘Could the ectopic beats by themselves be causing me damage’
Here it is important to understand that any heart rhythm disturbance in itself signifies one thing and one thing only – ‘mechanical inefficiency’. The heart is a pump and its job is to pump blood around. To do so most effieicntly it has to beat regularly. If there is any irregularity, all it means is that for the duration of that irregularity the heart has become inefficient. This ineffiency could damge the patient provided it is sustained and prolonged. Ectopics , however, by very nature tend to be transient and usually last 1to 2 beats and then are followed by a normal beat and therefore by definition represent unsustained inefficiency and therefore don’t cause any damage. Could a big burdern over a 24 hour period cause damage to the heart? There is now some evidence that a huge number of ectopics over a 24 hour period (more than 20,000) can cause the heart to weaken. If the heart beats 100,000 times an day and 20,000 are ectopics i.e less efficient then the kidneys end up getting only 4/5th of the blood that they are used to and this causes them to start absorbing more water from the urine to restore the circulating volume and over a period of time this causes the heart to stretch and weaken.
However the good news is that if the ectopics are then suppressed, the heart usually strengthens back up again. This is another reason why a holter monitor can be helpful because it can give you an assessment of the burden of ectopics.. If the burden is a few hundred or even a few thousand then very unlikely that the ectopics in themselves will do you any harm.
So once you have answered those 2 questions, you can be reliably reassured that no harm will befall you and often that reassurance can go a long way to getting rid of them.
Here is a link to a video I have done on this subject