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When symptoms don’t correspond to the disease…. but at times they do
To live we require oxygen. This fundamental chemical element arrives to all cells in our
organism through red blood cells which can be found in our blood, and the organ which
enables all red blood cells to circulate around our organism is the heart. In order to “pump”
blood, the heart needs to contract and this is possible only when the cardiac muscle gets
“excited” regularly and harmoniously by periodic waves of “electricity”. This electricity,
produced in specific “command pacemakers”, is then funnelled through “canals” up until
the muscle fibres. The physical and chemical mechanisms implicated in the genesis and in
the transmission of the electricity in the heart are extremely complex, and for the purpose
of this article, we wont go into too much detail.
Arrhythmias are anomalies of the genesis and/or the transfer of the electrical
current in the heart. The organ’s activity is not harmoniously connected at the necessity of
the body’s oxygen anymore, and the electrical current is produced and/or arrives to the
cardiac muscle in a disorganised and chaotic manner. These anomalies, more commonly
called “arrhythmias”, disturb the pumping function of the heart and could create symptoms.
Different types exist, and depending on their genesis, their length and the degree to which
the pumping of the heart is affected, they can be perceived in different ways.
Arrhythmias’ most common symptoms are “palpitations”, where people feel their
own heart beats. Normally, we should not feel our heart contracting, just like we don’t
realise that the kidneys continuously filter our blood, or that our liver synthesis and
degrades night and day, 24/7 almost all substances that circulate in our blood stream. The
moment where we become conscious of our cardiac activity, and we feel our heart beats,
we refer to this as palpitations. The beats we can feel, can present themselves
sporadically, or with higher frequency, at regular intervals or again, chaotically, for a few
seconds or for longer period of times (minutes, hours), or even for days, etc. Following the
typology of the arrhythmia, the palpitations will therefore “bother one another” as single
sporadic beats or in more organised ways and fairly long-lasting. We should mention
though that not all patients feel palpitations during arrhythmias. Many do not come to
realise their heart’s abnormal activity and when questioned, they would state: “I don’t have
any palpitations”. I would like to tell you about one of my patients who I have known since
he was an 8 year old child. Today in his mid twenties, he has suffered all his life of
ventricular extrasystoles. I can say he has grown up with his ventricular extrasystolic
arrhythmia ! On the 120.000 beats he would normally have in 24hrs, 50,000 are
extrasystolic beats. Having said this, he does not feel any one of them! On the other hand,
it is also true that not all palpitations are arrhythmias and this seems to me as good news!
Many individuals take continuous electrocardiographic monitoring (Holter exams), they
would note down the precise moment when they had “the typical sensation of palpitations”,
but the device would have not registered any arrhythmias.
When arrhythmias present themselves sporadically, we can feel the beat “every
now and then” or like “a pause”, “a missing beat”, or a “strong hit in the chest”. Other
patients describe this differently, like a “ball rolling down the stairs”, “a thud”, “a sense of
emptiness in the chest”, “epigastric emptiness”, etc. It’s a very common form of palpitation
which corresponds more to the extrasystoles. When on the other hand the arrhythmia
endures (and is usually of high frequency), the palpitation is expressed as “fast beats”,
“heart exiting the chest”. These sensations can often be localised over the sternum, below
the left breast or in the neck. In this last case, the classical sensation of “heart in the neck”
can be felt. When the arrhythmia is also quite fast, the sensation is extremely unpleasant
and in most cases it causes agitation, distress and pure panic of what could happen. In
other cases though, these feelings could be considerably different. I remember one of my
patients, an elderly woman who suffered brief episodes of atrial fibrillation, which she was
able to pin-point (and fairly accurately too) and identify as “small sheep in her chest”. Other
times, the same arrhythmia would make her feel a “whoosh in her chest”. Another patient
referred to it as “a gurgle in her heart”.
While palpitations are the consequence of directly perceiving the abnormality in the
heart rhythm, other symptoms exist which accompany arrhythmias but which are
secondary to an arrhythmic effect. If, for example, the arrhythmia is very fast (the cardiac
frequency increases considerably) or very slow (the cardiac frequency decreases
significantly), this could in some occasions result in a decrease of the blood pressure. The
pressure decrease, could express itself through, “asthenia”, “tiredness”, “fatigue”, or
feeling of “dizziness”. The same low blood pressure becomes the cause of bad blood flow
circulation in the brain, and this is how an arrhythmia with a too high or too low cardiac rate
decreasing the blood pressure can express itself (indirectly) with symptoms of low blood
pressure syndrome which could have a completely different cause (blood-loss, profound
sweating, loss of liquids due to vomit, diarrhoea, etc.). The extreme form of secondary
symptom in some arrhythmias is “the syncope” or fainting-fit. As the term suggests it, the
fainting-fit is the sudden loss of conscience with fall to the ground. Another case I followed,
who dealt with a young girl who, as many other people, to wake up in the morning to go to
school would setup an alarm clock. A few seconds after the alarm would go off she
would… faint. Obviously no one believed this story as they blamed this to “no motivation in
going to school”. Luckily, following specific investigations, it was noted that the sudden and
unpleasant sound of the alarm clock lead to the appearance of a severe ventricular
arrhythmia which caused…. a real syncope.
Another potential way for arrhythmias to express themselves is through
“shortness of breath”. Similarly to the fainting-fit, it is described as a secondary symptom.
Considerably fast arrhythmias reduce the necessary time for the ventricular to fill. The
blood overstays above the ventricle, in the atria and in the lungs. These phenomenons
unleash a sort of “breathing difficulty” that is “the shortness of breath” symptom. In
arrhythmias with extremely high and persistent cardiac rate, breathing difficulties begins in
a sharp way, just seconds or minutes before the outbreak of the actual arrhythmia. In
contrast, in arrhythmias with high cardiac rate, but not as severe, the symptom can occur
days or even weeks after the outbreak of the arrhythmia. It’s the classic case of cardiac
failure which in some occasions occurs when the normal cardiac rhythm is replaced by the
atrial fibrillation.
High tachycardia frequencies determine a decrease the blood flow through the
heart’s arteries (the coronary arteries). In some individuals, who already present shrinkage
of these arteries with reduced blood flow towards the heart muscle, the tachycardia
produces a further aggravation of the phenomenon. The further reduction in coronary
circulation could generate an insufficient oxygen supply to the cardiac muscle. The
medical expression for this phenomenon is “anginal chest pain”. During my time spent in
the Coronary Unit, I can recall of a patient with severe coronary problems who was waiting
to undergo a coronary artery bypass surgery. This patient was monitored and presented,
at different intervals, tachycardia of ventricular origin which lasted less than 10 seconds.
Anyway, even though short, the tachycardia still went at 200 beats per minute and every
episode was accompanied by typical angina pectoris.
Patients affected by arrhythmia, are able to identify both the beginning of the
disturbance as well as the end. The cease of the arrhythmia provokes a sensation of
“sudden calm”, of “end of chaos” or “back to normal heart beats”. In the vast majority of
cases everything finishes just like nothing had happened, but in other cases, one could
have the urge to urinate. The stimulus of the diuresis is a common characteristic for a
number of arrhythmias of atrium origin. This symptom brings me back memories of an old
patient of mine. One day, while driving his car, he experienced another episode of
tachycardia followed by an urgent need to urinate. He spotted a bar so he got off the car
as fast as he could without locking it, parked it in a non-parking area (Italian style) because
the urge became “unbearable”. He then went into the bar, asked for the bathroom, and
managed to urinate. Once finished, he thanked the owner of the bar, and left, only to find
that … his car had been stolen in the mean time. I recall he told me that “it was the most
expensive bathroom stop of his life”!
Some patients talk about very peculiar symptoms and a lot rarer. I remember a
young woman affected by a congenital cardiopathy for which she underwent several
surgical procedures. At one stage in her life, she all of a sudden started to suffer of very
fast and extremely unbearable episodes of atrial tachycardia. What will always remind me
of her are the “very violent hits, extremely painful in the chest” sensations who she felt as
initial signs, at the beginning of the tachycardia. Another patient I have followed in the
Intensive Care referred to it as “a sensation of extreme heat in the chest” before every
brief episode of severe bradicardia. Every time he stated “I am very hot doctor, very hot in
the chest” I used to look at the monitor and see a severe heart block which determined a
slow-down of the heart rate….. to 25 beats per minute.
In some cases, it’s not the patients who describe the arrhythmia, but the people
next to them! I am thinking of the mothers who while holding their babies to the chest, told
the paediatrician they could feel “their small heart beating very fast”. We could position in
the same category, all individuals carrying a mechanical valvular prosthesis. During the
nocturnal silence, the partner is usually attracted by the bizarre ticketing of the prosthesis.
The partner will be the one to reveal this to the doctor, as well as noting whether it was
beating “too fast” or at “irregular intervals”. While on the valve prosthesis subject
(especially the old generation prosthesis which tended to be extremely noisy) and of high
frequency atrial fibrillation, I recall a case concerning a couple; the woman was holding a
very loud mitral prosthesis and atrial fibrillation, and just as normal, she used to sleep in
the same bed as her husband. At this stage one would expect the husband to change
bed/room due to the noise. BUT NO ! During the silent night, the ticketing from the valve
would prevent the husband from sleeping, often resulting in him waking her up, as he
believed the valve did not make as much noise when she was awake. After a few
sleepless nights….. his woman changed room.
The case that really left me startled though was one concerning a patient of mine,
who underwent surgery for mitral valve replacement for a severe rheumatic malfunction.
For several years she had also suffered of atrial fibrillation which in any case had not
disappeared after surgery and was chronic. Over seven long years had gone by since the
surgery, and one morning she called me asking me to see her as for a number of hours
she had felt “numerous palpitations” and her heart “in great disorder”. After less than an
hour she was laying down on my private practice clinic and was continuing to experience
these so-called symptoms. I performed an ECG which I will never be able to forget: the
woman was in sinus rhythm. Used to a life-long disorganised rhythm of her atrial
fibrillation, the return of normal rhythm caused arrhythmic symptoms…. Unbelievable, but
true !
Vladimir Guluta, MD