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Heart Arrhythmias in Adults and Children (Drs. Chung and Aziz 08/19/14)

Friday, March 21, 2014 - Noon


Arrhythmias (irregular or abnormal heart beats) are very common and are often a mere annoyance. However, they can also be responsible for life-threatening medical emergencies that may result in cardiac arrest and sudden death in both children and adults. There are several different types of arrhythmias ranging from atrial fibrillation to ventricular arrhythmias and even inherited arrhythmia disorders. Treatment options for these conditions depend on the type and severity of the arrhythmia. Dr. Chung and Dr. Aziz answer your questions about arrhythmias in children and adults.

More Information

Atrial Fibrillation

Ed95: I'm a 59 yr. old male with Afib, twice cardioverted. I was previously on Multaq for about 18 months, but eventually it became ineffective. I have now been permanently out of rhythm for almost two years and for the most part asymptomatic. My question: Is an ablation now off the table for me due to potential remodeling? If not, is there a time table where eventually remodeling of the heart will eliminate the ablation option for me? Thanks.

Mina_Chung,_MD: Ablation is not off the table, though the success rates would be lower. Another antiarrhythmic drug and cardioversion could be tried to restore sinus rhythm and initiate some reverse remodeling before you consider ablation.

trele: Is Tikosyn an effective treatment for afib. What are the risks?

Mina_Chung,_MD: Tikosyn can be effective for people with atrial fibrillation. We are mainly concerned about a potential for excessive prolongation of an interval, called the QT interval, which can predispose to rapid lower chamber (ventricular) arrhythmias that could be life threatening. We generally admit people for at least three days to monitor and start the drug. This allows us to adjust the dosage to make it safer.

emadler: I am a 79 year old male who seems to be getting afib every six weeks or so that lasts for about one to two days and then goes away and I feel normal. I have tried to observe if there so event that could cause it, perhaps overeating and then some kind of exertion. It seems to be irregular-irregular pulse. Can this episode of overeating and exertion be a cause of afib? Is there any that I can do other than waiting it out suffering the symptoms? I have had x-rays of my heart and the arteries are clear! Would more exercise help like walking even more than I am?

Mina_Chung,_MD: Hard to know if the overeating and exertion are causing your atrial fibrillation. The esophagus (swallowing tube) does sit behind the left atrium and pulmonary veins, where atrial fibrillation often starts. There are good treatments for atrial fibrillation that can aid your symptoms, including antiarrhythmic drugs and/or ablation. Keeping up exercise is generally good for you and it would be great if you continue to be active and exercise.

tcalabro: I have had Paroxysmal Afib for over 10 years. In June, I started a regiment of Pradaxa (Two 150 mg per day). Prior to Pradaxa, my BP was 120/60, with a resting HR of 53. I do cardio 6X per week. On Pradaxa my BP dropped to 98/60 with a HR in the 40s. In my estimation this is what's happening: Pradaxa makes your blood less viscous. It is effective at achieving blood thinning that causes your blood to flow more easily and your BP to drop. If blood viscosity decreases blood flow will increase and systolic BP must then decrease. Lower blood viscosity lessens the work required for the heart to pump blood, lowering the HR. Is there must be a blood test to indicate the effectiveness of Pradaxa and perhaps through dosage modification regulate my blood viscosity to a level adequate to prevent clotting, yet not thin enough to reduce BP and HR.

Mina_Chung,_MD: Although sounds logical, we usually don't see much BP dropping on Pradaxa. Did you start any other medications to treat your atrial fibrillation at the same time? Some of these could lower BP or heart rate. We typically don't monitor blood tests for Pradaxa, though a test called an ECT could be used.

Murphy1523: Please discuss new methods to correct a-fib and a-flutter; such as hybrid ablation.

Mina_Chung,_MD: Hybrid ablation incorporates surgical and catheter methods to approach atrial fibrillation. This may or may not be necessary for specific patients with atrial fibrillation. The approach should be individualized. At this time it is difficult to say if these types of procedures out-perform catheter ablation procedures without more data.

Japanese100: My husband recently had atrial fib; with severe pain in both arms and heaviness in chest with NO warning. After an overnight stay in hospital with negative heart enzymes, negative echo and stable stress test he was discharged home with instructions to take Metoprolol 1 po BID if pulse is 100 + (pulse rate now is anywhere from 48 to 52). He is 81 w/ history of double by-pass in 1997, two heart stents in 2006 and one stent in 2008. This atrial fib attack put him completely out of commission ... How can we better prepare for a repeat performance of this frightening experience?

Mina_Chung,_MD: Usually treatment involves addressing stroke risk with anticoagulant medications and controlling the rate and rhythm with rate controlling medications (like metoprolol) and antiarrhythmic drugs. If AF doesn't respond, ablation could potentially be considered.

hoagie0013: I have had a-fib and irregular heart rhythms for10 yrs. I have had three ablations and am still having doctor sent me to see a doctor at U of Penn for second opinion because he felt that my problem was too close to AV node and he didn't want to risk ablating tissue with heat. He felt dr. could use cyro to ablate tissue that needed to be ablated. Doctor informed me that he didn't need to use cyro and could use another route than my other dr. to get at problem. My questions are should I get 4th ablation and are you familiar with this doctor?

Mina_Chung,_MD: The doctor you suggested is an excellent electrophysiologist. If he thinks you are a candidate for a 4th ablation and can help you, then that could be a good approach for you.

Hawg: In the past when I have experienced A-fib or A-flutter, my heart rate has been high (90-110) but for past few weeks when I go into A-fib my heart rate has been in the 50's. Avg. for today is 88/62 with heart rate 57. Is there any significance to this change in pattern?

Mina_Chung,_MD: Would get an ECG in your atrial fibrillation to help determine its significance. Often heart rate is reflective of medications you are on to control the rate and rhythm. In some, but not all people, alcohol can be a trigger for atrial fibrillation.

joed: I am 77 years old. Twenty-four months ago had cardiac arrest [defibrillated 12 times], into a-fib around May 19, 2014. Placed on pradaxa at once, then to an electrophysiologist twice. Said i was in persistent a-fib and could be cardioverted or do nothing. Said I could go back to gym after cardiologist told me to stop. I am back to 50 min, five days per week on treadmill [have run nine marathons previously [last one around 1993]; back to drinking beer, have slight headaches and lightheadedness sometimes and get very tired sometimes. Feel stuck in the middle and do not know whether I should continue to "watch and wait" and also if my exercise is too much [holding myself back from increasing to one hour per day. Any suggestions [hope I have given you enough info].

Mina_Chung,_MD: We need more information to answer your question - particularly on the cause of your cardiac arrest, your heart function and if you are in persistent atrial fibrillation.

jeg1098: This question is about my husband. A 63 year old in excellent health who had A Fib (undetected) which led to CHF. This took place in April 2014. Through cardio version his heart returned to normal rhythm. His heart was pumping at 18 % in June. He had several episodes of V Tach and now wears a life vest to see if his heart will heal. He will have a muga scan Friday to see if that is the case. What is your opinion as to his heart healing. Do you think this can happen? He is on lasix, toprol, lisprinorol, pradaxa. As of last Friday his blood work was normal.

Mina_Chung,_MD: I would be optimistic that it could improve, especially if the heart weakening was due to rapid rates in atrial fibrillation and since he is taking good medications for his heart failure.

Lmg93: I was in the hospital for afib incident a couple weeks ago my third in three years. Last time I was in the hospital was two years ago in March. I always convert on my own so I have not had a cardioversions. My cardiologist then sent me to an electrophysiologist to see about ablation. He told me I wasn't a candidate as I was A-typical and they would have to induce the Afib to do the ablation. I never miss my meds which is flecainide 50 mg twice a day, lisinopril 20 mg, 5 mg amlodipine, xarelto, keep sodium at 1500mg, walk two miles a day, stay hydrated and sleep seven to eight hours at night. I was recently taken off of 3.125mg of carvediol as my heart rate was too low but do not need a pacemaker. I follow all of the rules and I am so frustrated by all of this. Should I get another opinion about ablation? Thanks, Lloyd

Mina_Chung,_MD: It is reasonable to seek another opinion. There are options, including ablation, continued medications, etc. The main reason at this point to pursuing an ablation would be to reduce your symptoms. The frequency and your symptoms would go into this decision.

saintrose: My arrhythmia was increasing even with meds. I decided to have an ablation, but last week while having a TEE the day before the procedure, my doctors found a small heart tumor on the right side of my heart. I have an appointment with a surgeon. Is this connected to my A-fib? Do you have doctors who specialize with this type of problem?

Mina_Chung,_MD: It could be, depending on which chamber it is located. We do have cardiologists and surgeons here who could help you with this.

beatright: I'm a 68 year old female who has undergone two ablations (June 2013 and March 2014). Both ablations were over 10 hours each and the second one was successful in stopping my A-fib, but not my arrhythmia which causes my heart rate to go up to over 160 bpm following minor exertion. Since my second ablation I have been extremely tired and after minor exertion short of breath. My doctor indicated I have ventricular tachycardia and an atrial flutter which might be corrected with a third ablation focused on the right atrium, and also a possible bi-ventricular pace maker. I'm taking warfarin 2.5 mg daily, lopressor 75 mg three time a day, and digoxin at 0.125 mg daily. I'm concerned about undergoing a third ablation and possible having a pace maker installed. I was giving little assurance that I would feel any better. What do you think about the electrophysiologist's recommendation? Do you have any suggestion on what I should do next.

Mina_Chung,_MD: We would need to review your records to determine the best treatment options for you.

Murphy1523: Five years ago I had my mitral valve repaired, maze performed and my first cardioversion. Today at 1:30pm (I may miss some of the chat) I am going in for my 7th cardioversion. Have also had two ablations. Please update us on new techniques like hybrid ablation or other recommendations for people that have chronic A-Fib. Thanks Bill

Mina_Chung,_MD: Hybrid ablation incorporates surgical and catheter methods to approach atrial fibrillation. For chronic, persistent atrial fibrillation or flutter, it should be determined if your problem is a flutter or fibrillation. Sometimes a hybrid approach might be helpful for some of these difficult cases. At this time it is difficult to tell if these approaches out-perform catheter ablation procedures without more data. There are also some studies investigating ablation of "rotors" in the atria, new catheter/electrode configurations, and energy sources. Again, these approaches require more study. Good luck on your cardioversion.

joekiebel: On July 29, 2014, there was a study published by the University of Michigan Health System titled "Ablation increases survival for adults with atrial fibrillation". Can you comment on this study and whether patients on drug therapy who have had a stroke should give strong consideration to having an ablation as soon as possible.

Mina_Chung,_MD: The study was a retrospective analysis of patients who underwent ablation. It showed that people who were able to maintain sinus rhythm after may have lower cardiovascular mortality. This was also shown in the AFFIRM study which compared rate vs. rhythm controlled by medications. People who were able to maintain NSR, had better outcomes and likely are a healthier group of patients. We await the results of CABANA, a randomized study of ablation vs. medical therapy for afib which will determine if patients live longer with an ablation approach.

SKB14: My Dad (73 years old) had an Emergency mitral valve replacement (biological) surgery on July 9th (a couple of chords had ruptured), along with a double bypass. After a day or two after surgery he did go into A-Fib. Medications were given at hospital and was sent home with 400mg of Amiodarone (including other meds and Coumadin). EKG was done and the dose was changed to 200mg this week. His HR is around 88. Is A-fib after surgery normal and how long does it last. When the dose of Amiodarone is reduced what signs should you look out for and should another type of medication be increased to keep balance. Is Amiodarone toxic? Will the heart rate normalize while recovering (his hr was in the 60’s before the surgery). How long does the patient need to take Coumadin. A biological valve has a shorter life than a mechanical valve. When needed have the biological valves been replaced in the past. Any nutrition tips for heart healthy weight gain. Thanks

Mina_Chung,_MD: Atrial fibrillation is a common complication after surgery, particularly after open heart surgery - it occurs in 20 - 30% of patients after CABG and 40-60% after valve surgery. It is generally self-limited and most people are back in sinus rhythm by four - six week follow-up. Amiodarone is a common drug used to treat this. Typically it would be used short term for 4 - 6 weeks. When the dose is reduced or stopped then signs of atrial fib include shortness of breath, fatigue, lightheadedness, fatigue. If the patient is still in atrial fibrillation as the amiodarone is weaned off then additional medication or treatments may be required to control the rate or rhythm. Amiodarone does have long term side effects but in the post op setting use is usually short term. Hopefully the heart rhythm will normalize on amiodarone - that is the intent.

PVCs and Ventricular Tachycardia

PistolPete: Age 72. Bi-Cuspid Aortic Valve replaced 2011 with Bovine valve. On 20 mg Bystolic daily. Weight 175LB. No other health issues. Currently getting 30,000 PVCs per day. Ablations have been unsuccessfully able to correct PVC problems. I do not sleep well and am tired most of the day. What is next for me?

Mina_Chung,_MD: Depending on your heart function and where these are coming from, another ablation could be attempted or other medications tried.

kahuna8: 1.POLYMORHIC VENT. TACH. (PMVT). Would this be corrected/improved by aortic valve replacement (0.9 valve/50 mean gradient)? or is this is a separate problem. 2. What are risks involved by having Left Atrial Appendage Closure (LAAC) to correct AFIB during open heart surgery to replace aortic valve? Is LAAC performed pre-emptively - I understand it would greatly reduce onset of AFIB. THANK YOU! HWH

Mina_Chung,_MD: Polymorphic VT might but might not improve with the aortic valve replacement, but fixing the aortic valve may help the stresses that the ventricle faces. There is not much risk to closing the left atrial appendage at the time of surgery. It usually is done in patients with atrial fibrillation to reduce the risk of stroke from clots that tend to form in the left atrial appendage in patients with AF; it typically does not reduce the onset of atrial fibrillation.

MikeyCski: I have been diagnosed with ventricular tachycardia and had a dual chambered pacemaker (set at 50 beats per minute ) installed two years ago. I am on Bisoprolol and Lisinopril. I do moderate cardio workouts for about 2. 1/2 hrs. 3 x's /week and lift weights approx. one-two x's /week. When doing cardio, my pulse rate stays low ( at or below 100 ) and then will quickly spike at 180-200 and go back down to 100 within a minute. Sometimes, my pulse rate goes down to 90-95 when I'm working out harder. Should I be concerned about either of these twp incidences ?

Mina_Chung,_MD: Looking at the diagnostics of your pacemaker could help figure out if you're having any more ventricular tachycardia and how well your heart rates have been responding to exercise. If your pacemaker doesn't have these diagnostics, you could wear an event monitor to record your rhythm during these pulse changes. It's probably worth looking into.

msfcommons: Does the presence of a V. Tach in a holter monitor study (24 hr.) automatically indicate that an ICD is indicated ? 63 yo male Acute MI 11 years ago.

Mina_Chung,_MD: It does not automatically indicate an ICD. The symptoms, duration, and ventricular function are important components of a decision to implant an ICD in the setting of someone with prior MI.

llballard8: I am 42 next week and have been told I have ventricular tachycardia and possible atrial flutters. I am currently wearing a 30 day monitor. I also have a VSD. I have been told I will likely have a heart cath and possible ablation. I don't live near Cleveland so how do I find a good EP and what questions do I ask? I'm very scared because I have no idea what to expect, how safe this procedure is, etc.

Mina_Chung,_MD: We would welcome you to Cleveland if you choose to come here. Complicated problems are often what we see. If not, you could check the Heart Rhythm Society website for electrophysiologists in your area - You'll probably want to ask about what your heart function is, whether you need to have the VSD repaired, how serious or life-threatening the ventricular tachycardia is, etc.

jplas3: If a defibrillator is triggered by an episode of vtac, does it shock? If vtac continues after the shock, does it continue to shock over and over again? At what point does it stop shocking and how is that controlled?

Mina_Chung,_MD: A defibrillator is usually programmed with certain rate criteria - so if the VT is over a certain programmed rate it can either deliver pacing therapies or go on to deliver shock therapies. If the rate is very fast or it is known that the pacing therapy does not work ahead of time - it may shock immediately. Usually a defib is programmed to shock more than one time - it could be approximately three - six more shocks. It stops shocking if it detects the rhythm returns to a lower rate or normal rhythm. It does not deliver the additional shocks if it is not necessary.

Sudden Cardiac Death

cherieanddave: We lost a 26 year old daughter to SCA in 2001. The entire family has been tested for any hereditary condition. The autopsy showed a perfectly healthy heart and we are still looking for answers. Would this chat be beneficial to us?

Peter_Aziz,_MD: Sorry for your loss. Our approach to familial screening in sudden cardiac death (SCD) consists of ECGs; and sometimes echocardiograms. In patients with unexplained SCD, we often assume an arrhythmia to be the cause. It would be important to know what testing the family has done previously but screening ECGs would be a reasonable start. Doing genetic testing on blood or tissue from the deceased relative can be helpful.

shiva65: My nephew died of sudden death this year - I am wondering about the other children in the family. Should they be tested? What type of testing should be done?

Peter_Aziz,_MD: Definitely yes. Our common approach to SCD in pediatric patients is to perform screening (physical examination, ECG) in all first degree relatives of the deceased patient. Autopsy information if done could also provide some insight as to the cause and may help tailor screening.

Heartacheforlife: My seventeen year old son passed suddenly of Cardiac Dysrhythmia 8/19 of last year. He had no prior symptoms leading up to his sudden death with the exception of acid reflux. My 21 year old son has had genetic testing for Long QT, Short QT, Brugada, Wolff Parkinson White, etc., all tests came back negative. He has had an echo stress test and EKG's. All were normal. This son has had symptoms of irregular heartbeats and has been told by his cardiologist and electrophysiologist that he has an extra beat. His last episode of heart palpitations resulted in him wearing a waterproof monitor for two weeks. He had worn a Holter monitor for one month prior after my youngest son passed. Since his palpitations are not on a regular basis a Linq Monitor has been implanted in his chest. Both of my boys were diagnosed with reactive airway disease. The older son has had it since age two and uses an albuterol inhaler on a regular basis. Is there anything I should look into to make sure nothing is missed?

Peter_Aziz,_MD: Based on the information presented here, it appears that a thorough evaluation has been performed in your 21 year-old. I would consider a similar evaluation in all first degree relatives. Often times inherited syndromes can affect one child and not the other. In this case, screening the parents can be helpful.

Long QT and Short QT Syndrome

karensue: I am a female experiencing approx. 40,000 PVC's each day. My cardiologist has recommended ablation surgery. What are the long QT and short QT syndromes? My father passed suddenly at age 60 and his mother also passed at the same age. I am 59 but it was recommended I see a cardiac specialist back in 1974 when I was 19 when my first EKG was taken. I'm 59 now. Thank you

Peter_Aziz,_MD: Long QT and short QT syndromes involve problems with the electrical relaxation time of the heart. Long QT can cause passing out spells, typically associated with exercise or exertion. Short QT can cause atrial and ventricular arrhythmias and also passing out spells. Both of these syndromes are causes of sudden death though none of them are associated with PVCs. 40,000 PVCs in a day are considered frequent and most often requires therapy. Typically this degree of PVCs are managed by a heart rhythm specialist.

Kmucci: First off, hello to Dr. Aziz! My son Colin was one of your patients that you would regularly see during his seven week stay during the summer of 2010. Colin came in at two days old and was diagnosed with Long QT and had a pacemaker implanted. Colin is now four and is a regular patient of Dr. V. Genetic testing showed Colin has both types 1 and 2. (Type 1 from me and type 2 from his father). He had a rough start but after his chest wound healed following an infection, he was fine. Since then, he has had NO arrhythmias and his pacemaker has been turned off but not removed yet (should be this year now that he is four). He takes Mexilitine and Propranolol. My question is, he is taking mexilitine because the doctors THOUGHT he had type 3, but this was before genetic testing. Dr. V feels we should not change anything since its working for him. But have you found in your studies that it might be an issue if he is taking a medication that is possibly not needed?

Peter_Aziz,_MD: Greetings, great to hear from you! A judgment call to say the least. I certainly defer to Dr. V's expertise. Fortunately, as Colin gets older, his risk will likely decrease along with his QTc (relative to infancy). Continuing mexiletine is purely a risk/benefit assessment and there is no right answer. I certainly see Dr. V's logic and approach in continuing the medicine and I encourage you to discuss with him further, particularly if you feel strongly about having him off. Please send him my warmest regards.

Melissa_d: Many thanks for taking my question. I have recently been diagnosed Long QT Syndrome. I'm on daily meds now for two months, and I'm feeling incredibly sluggish physically and mentally. I'm unsure whether or not to accept this new sluggish feeling as my new "norm" or should I return to my EP and adjust my meds. Could changing the type of Beta Blocker change the impact this drug has on me? In the mornings I take 25gm Atenolol, 2 x Slow K and 25mg of Spirononolactone and another 25mg Atenolol in the evening. Apart from my QT woes I'm a an incredibly healthy 36 year old Mother of three. Any feedback to my question would be appreciated. Cheers, Melissa from Melbourne, Australia.

Peter_Aziz,_MD: Excellent question and very common issue. I will share with you my approach. As beta-blockers are the crux of long QT therapy, we tend to be rather patient with "finding the right dose." In my practice I find that some patients are quite sensitive to beta-blockers. As such, if allowed, I will very slowly titrate the dose to therapeutic, sometimes over several weeks. I try to find the dose just below side effects are seen, and will perform an exercise stress test to ensure that the dose is "effective." Additionally, I tend to shy away from atenolol and use nadolol or propranolol almost exclusively for long QT patients. I encourage you to discuss this with your physician as there may be other factors involved in the decision. Hope this helps

Kadie: When will sports participation guidelines be revised, in particular regarding Long QT Syndrome? Thank you

Peter_Aziz,_MD: I am particularly interested in this topic and, hopefully, new research will continue to encourage us to revise our practice. I think the sports guidelines will be revised. I discuss this topic with my patients and their families at length and often times the decision to participate is reasonable as long as the risks are minimized and fully understood.

tolerate: Some members of our family have been identified with a Class II mutation LQTS and all have normal EKGs (toddlers, children, teens and adults). Without any symptoms, can you give an opinion on risk? We avoid the bad drugs list. How likely is it that this mutation is not significant?

Peter_Aziz,_MD: The class II mutations are difficult to manage to say the least and I appreciate your question. Though it is difficult to opine on your specific familial mutation without knowing more details, if no family members have signs of this disease though have the mutation, it is less likely to be "real." In these scenarios I would still recommend avoidance of QT prolonging medications. If the gene testing was performed several years ago, it is my practice to readdress the mutation with the lab to see if is reclassified. Often times we find more families with the mutation that offer some insight as to its implications.

ritaw6699: Advice on ADHD stimulant medication and LQTS type 2 - Thank you

Peter_Aziz,_MD: The continuation of ADHD medications in LQTS is a common question. If the benefit of ADHD medications is strong and tangible, I typically do not discontinue the medication. I consider ADHD medications to be relatively safe with the risk being theoretical at this point. I often attempt to find a non-stimulant type if possible (strattera for example).

jogger7: I have a patient with genetically confirmed LQTS with no symptoms or events. She is entering into the 7th grade. The mother brings an AED to all of her volleyball practices, however, the school has refused any AED assistance. Any suggestions?

Peter_Aziz,_MD: This is a difficult one. I applaud the mother's proactive approach in bringing a personal AED. Does the school have one? We often times find that schools are particularly reluctant to take any responsibility in these situations. I will typically try to contact the school and discuss a plan of action with a written description of what to do in an event.

Brugada Syndrome

jonny26: I was diagnosed with Brugada Syndrome two years ago. I was lucky in that my Brugada presented as a classic heart attack resulting an ICD implant. Since that time, I have developed SVT and very often, I’m finding myself experiencing all the hallmarks of a heart attack. When I go to the hospital, everything checks out as normal. My Doctor has gone so far as to do an EP study to find the source of the SVT with no success. I have been put on Diltiazem to control the SVTs. January of this year, I experienced a TIA. Also, my cholesterol which had ALWAYS been extremely low spiked to over 400 warranting being put on both Zocor and Plavix. Two additional TIAs were experienced in February and April of this year. I'd like to know what can be made of this? Should my Dr. Be doing more? Is this a function of the implant? Something, anything to ease my mind.

Mina_Chung,_MD: If you have a dual chamber ICD, it could be checked to see if you have atrial fibrillation, an arrhythmia that can be associated with TIAs. If you have a single lead ICD, then it will be less helpful, but you could wear an event monitor to try to see if you have atrial fibrillation. If so, then you might need to be on an anticoagulant (blood thinner). ICDs usually do not cause TIAs. You could also consider an echo and/or transesophageal echo to look for clots and verify normal positioning of the ICD lead(s).

Complete Heart Block

Charliegood: Dr. Aziz, what would you do with a 10 year old boy who has complete heart block. His heart rate is in the 50s. His cardiologist said he would not treat unless symptoms occur - but wonder at what age would you treat? He gets pretty tired through the day but other than that - that is it. Also - would you restrict any activities in this case?

Peter_Aziz,_MD: Good question. Fortunately there are very clear guidelines that dictate indication for pacemaker implantation in complete heart block. In pediatric patients I will implant a pacemaker for low average heart rates, ventricular heart dysfunction, or long pauses in the heart rate. Symptoms typically do not occur with pediatric patients with heart block although that would be another indication. The decision to implant is an important one as this would commit a pediatric patient to a lifetime of pacemaker replacements and the risks associated with it. I would not restrict a patient such as this for activities as long as the heart function is normal.

Postural Orthostatic Tachycardia (POTS)

Toddgalsmom: How does POTS (EDS classical and or type1 cause ) interplay on the arrhythmia prone heart? Two daughters in mid-twenties diagnosed with arrhythmias in their early teens (thought to be LQT but always told could be another type arrhythmias which has been in and out of all tests) have defibs since couldn't tolerate betas. Ehlers-Danlos diagnosed in twenties although all signs were there earlier. Their dad died at 44 of arrhythmias, and had many of same signs.

Peter_Aziz,_MD: It sounds like this clinical situation is complex. The first place to start is of course figuring out the underlying diagnosis. Often times, there is overlap between symptoms of POTS and long QT syndrome. In those cases, a specialist can implement exercise testing or genetic testing to distinguish between the two. Further evaluation of their father's history may provide further cues though we understand this is a sensitive subject.

Arrhythmia in Children – general questions

charla-charla: My eight year old son was just recently diagnosed with arrhythmia and slight murmur. The cardiologist said that there was nothing to worry about, because there are no other symptoms. But there are times when he feels his heart racing - and gets dizzy. After a bit, he sits down and he will feel ok but these episodes scare me and they are very scary for him. Is it nothing to worry about?

Peter_Aziz,_MD: It would be important to know what your arrhythmia diagnosis is. We often times will prescribe ambulatory monitors to document a patient's heart rhythm during a symptomatic event. Perhaps something like this would be beneficial in figuring out if your son's symptoms are related to the arrhythmia.

Wolff Parkinson White (WPW)

lewisC: Two month old Great Grandson with WPW. What is the earliest age you have performed a successful Ablation?

Peter_Aziz,_MD: We have performed successful ablations in very young patients though those patients we perform those on are typically quite burdened by arrhythmia and unable to be discharged from the hospital unless they are treated. In patients with WPW our guidelines recommend elective EP study and catheter ablation around eight years of age. The risk of ablation increases in younger patients as they are smaller and instruments are generally intended for adult patients. If your grandson has significant arrhythmias from WPW, those can often be managed with medicines initially.

Sarcoidosis and Arrhythmia

WaveWolf: What types of arrhythmias are typical for cardiac sarcoidosis? Background: I have multisystemic sarcoidosis (lesions in brain, spinal cord, lymph nodes, lungs (40% function), eyes, bones, skin, liver, and bowel). I recently had an ablation to correct atrial flutter and irregular beats, which seems to have been successful. My cardiologist suspects cardiac sarcoidosis and has ordered a cardiac MRI, which Medicare finally approved. If there is notable inflammation in my heart, I will likely have both pacemaker and defibrillator implanted.

Mina_Chung,_MD: Sarcoidosis can be associated with rapid ventricular rhythms, as well as slow heart rhythms and conduction blocks.

Amyloidosis and Arrhythmia

jplas3: I developed afib in 2008. Cardioversion and sotalol kept me in sinus rhythm until three years ago when my local EP MD saw that I had LVH and a low voltage ekg. An MRI revealed amyloid. My EP MD took me off sotalol because of concern for pro-arrhythmia He knew nothing about amyloidosis. I went to Mayo clinic and was diagnosed with cardiac TTR WT amyloidosis. They told me that they would have left me on sotalol. When I got back to my EPMD he put me on amiodarone and cardioverted me again. It has been a horrible prescription to take with all kinds of side effects that I never experienced with sotalol. Mayo has now determined that I have LBBB and recommended a biventricular pacemaker. Also, I have returned to afib. I am going back to my EPMD for cardioversion and implantation of the pacemaker. My doctor at Mayo still feels that I would be ok with sotalol. Apparently, they feel that the normal anti-arrhythmic decisions do not apply to an amyloidosis heart. What is your experience?

Mina_Chung,_MD: There are some new investigational drugs being explored for amyloidosis. You could see one of the experts on this at Cleveland Clinic. Sotalol could be used, but could cause some slow heart rhythms. If you are a candidate for a biventricular pacemaker/defibrillator, that could be helpful and allow you to tolerate the antiarrhythmic drugs better.

Arrhythmia in adults – general questions

Gordon: I am interested in knowing what the opinion of Cleveland Clinic is concerning Hybrid vehicles and their effect on pacemakers and defibrillators. What do you think about the Mayo Clinic study of 2013 regarding this issue? Are there currently any more studies being conducted on this subject? I have been a subscriber of your Heart Adviser newsletter for 18 years and I have a Medtronic ICD that was put in in August of 2006.

Mina_Chung,_MD: No issues were identified in that study, which was an abstract presented at the ACC meetings. Further refinements are probably in progress for the manuscript.

harrywt: I have had Heart Arrhythmias for over 20 yrs. My Mother also had it. I am a 70 yr. old male and I have my Arrhythmias mainly when I get stressed, overly tired, anxious, too much caffeine. I had two ablations at different times about 12 yrs. ago. One for irregular beats and one for rapid beats. Solved my problem for a while. Most of my incidents now are from irregular beats and when the episode happens, it usually last for between one and four days. And then my heart goes back into sinus rhythm. I only take a baby aspirin when I have an episode. My QUESTION: What kind of danger am I in considering the information I gave you? Canceled a cruise to the Panama Canal, 14 days because I was afraid to go. Thank you - Harry

Mina_Chung,_MD: Difficult to answer without knowing your arrhythmia diagnosis. Is it atrial fibrillation or some other arrhythmia?

sylwex: I had my aortic valid replaced 1-1/2 years ago . In the last year, I have had episodes of arrhythmias with a heart rate of 144 with normal blood pressure. I have Graves disease and was treated years back with radioactive iodine. My thyroid function has been abnormal and is under treatment. Can my rapid heartbeat be as a result of my thyroid. My cardiologist says my valve sounds very good.

Mina_Chung,_MD: Yes, overactive thyroid function or over-supplementation with thyroid replacement therapy could lead to rapid heart rhythms.

hoagie0013: have had heart arrhythmia for last ten yrs. have had three ablations to try and stem the tide. Still getting arrhythmias. My question is if a person is anemic with iron deficient anemia and blood work showing readings of rbc 3, hemoglobin 11, hemocrit 32, and rdw 17, could this make symptoms of erratic rhythms worse. Also had many episodes of syncope. Could they be from the anemia. since receiving. thank you

Mina_Chung,_MD: Anemia could make symptoms from an arrhythmia less tolerable. It is difficult to be more specific without knowing what kind of any arrhythmia you have. Syncope can occur from anemia but generally the degree of anemia is worse than what you currently have.

gsnugent: Five years ago I had severe pneumonia symptoms accompanied by arrhythmia. Also, had several episodes of vasovagal syncope over the last 20 years, which is now under control by staying hydrated. The arrhythmia has never reoccurred. Is it likely that the extreme stress of the pneumonia caused a one-time arrhythmia that may not occur again without some type of extremely stressful event?

Mina_Chung,_MD: It could have provoked it, though difficult to tell without knowing what kind of an arrhythmia you have. There has also been an association of inflammation with atrial fibrillation.

gsnugent: I had only one instance of arrhythmia which occurred with the onset of pneumonia four years ago. Also, have experienced Vasovagal Syncope about eight times in the last 20 years. I am an adult male age 80. I have been taking a baby aspirin but discontinued a few months ago after reading the latest info on who needs to be on aspirin therapy. I exercise quite strenuously three-four times per week and otherwise in good health with no evidence of aspirin problems with stomach bleeding, etc. What would your recommendation be regarding whether or not I should resume aspirin therapy and if so, baby aspirin or full dosage? Thank you.

Mina_Chung,_MD: Assuming you have had no other cardiovascular disease, aspirin would be optional in your case. It might provide some modest reduction in cardiovascular or cancer outcomes, to be balanced by a higher risk of bleeding in your age group. One set of recommendations suggests low dose aspirin for age >/=50 at low risk for bleeding, and one set suggests aspirin for men 45-79 for prevention of MI and for women 55-79 for prevention of stroke. Please talk to your doctor about this question.

49dancer: Good Morning, Is medication always necessary in treating mild arrhythmias? Thank you.

Mina_Chung,_MD: No. not necessarily. Sometimes treatment is guided by your symptoms, the frequency and whether or not they affect your heart function. Also if the heart function is reduced, the arrhythmias may take on a more serious significance.

sandybeach77: When sleeping I'm sometimes startled awake by something I see, hear or feel. Today after a 25 min. nap I was startled and woke up. I felt a little like I'd had a slight seizure, although to my knowledge I've never had one. Wondering if my pacemaker is doing something weird. Have a-fib most of the time and it only paces about 2% of the time. Had the Pacemaker about 16 months. I take 50 mg Toprol, 180 MG Diltiazem and Pradaxa. Thanks so much.....

Mina_Chung,_MD: You could have your pacemaker checked to see if anything was picked up during that incident. Most pacemakers have diagnostics that would determine if you had certain rapid heart rhythms and a check could also let you know if the pacemaker and its components are functioning normally.

Stratichuk: Hello. I am asking in behalf of my mom who has been experiencing arrhythmias for the past two years. It's seems that unannounced her heart will start beating insanely fast like 160bpm. She seems to control it somewhat with medicine. She suffers from high blood pressure as well. It seems like her doctors can't do anything more for her. What would you suggest she do??

Mina_Chung,_MD: We would need a diagnosis of what her heart rhythm is during those rapid heart rates. If it has not been caught on the monitor, there are various ambulatory monitors that can be used for longer periods of time to try to catch these episodes.

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