The Normal Heart Rate
The heart’s rhythm is coordinated by its own electrical system. With each heartbeat, the electrical impulse begins at the sinus (or sinoatrial, SA) node, also called the heart’s natural pacemaker. The SA node is a cluster of specialized cells, located in the right atrium. The SA node produces the electrical impulses that set the rate and rhythm of your heartbeat. The impulse spreads through the walls of the right and left atria, causing them to contract, forcing blood into the ventricles.
The Heart's Electrical System
The impulse then reaches the atrioventricular (AV) node, which acts as an electrical bridge allowing impulses to travel from the atria to the ventricles. There is a short delay before the impulse travels on to the ventricles. From the AV node, the impulse travels through a pathway of fibers called the HIS-Purkinje network. This network sends the impulse into the ventricles and causes them to contract. The contraction forces blood out of the heart to the lungs and body.
The SA node fires another impulse and the cycle begins again.
The heartbeat is triggered by electrical impulses that travel down a special pathway through your heart muscle.
Heart Rate and Rhythm Differences Between Men and Women
Women and men are similar when it comes to the basic heart rate and rhythm. However, while the basic electrical system is the same (impulses originating in the SA node, traveling to the AV node, through the HIS-Purkinje, and then starting over), there are differences:
- Women tend to have a faster baseline heart rate
- Women’s ECG readings may be different
Women Have a Faster Baseline Heart Rate Than Men
First of all, on average, women tend to have a faster baseline heart rate than men. This difference is seen in girls, on an average, as young as five years old. There is also a shorter sinus node refractory time – this means that it takes a shorter time for the SA node to recover and become ready to fire an impulse again ¹
Women’s ECG Readings may be Different
The ECG (also called EKG or electrocardiogram) is a test used to record on graph paper the electrical activity of the heart. The picture, drawn by a computer from information supplied by electrodes placed on the skin of the chest, arms and legs, shows the timing of the different phases of the heart rhythm.
The p wave represents the electrical activity of the upper chambers of the heart (atria). There is a short pause followed by the QRS complex - the electrical activity of the lower chambers (ventricles) - and ends with a small T wave, the recovery phase of the ventricles. The QT interval is the distance from the beginning of the QRS to the end of the T wave and represents the time it takes for the heart muscle to contract and then recover, or for the electrical impulse to fire and then recharge.
On average, the QT interval is shorter in men than in women, beginning after puberty with a linear increase through the major part of adulthood to at least age 55. This period corresponds to the time period when androgen levels are highest in men. Therefore, androgen and estrogen levels may explain the gender differences in QT interval².
- Taneja T, Mahnert BW, Passman R, Goldberger J, Kadish A. Effects of sex and age on electrocardiographic and cardiac electrophysiological properties in adults. Pacing Clin Electrophysiol. 2001 Jan;24(1):16-21.
- Rautaharju PM, Zhou SH, Wong S, Calhoun HP, Berenson GS, Prineas R, Davignon A. Sex differences in the evolution of the electrocardiographic QT interval with age. Can J Cardiol. 1992 Sep;8(7):690-5.
Certain types of arrhythmias are more prevalent in women than in men.
- Supraventricular Tachycardia (SVT) or Paroxysmal SVT (PSVT) – a rapid heart rate that originates above the AV node, in the atria. SVT is common in both men and women, but more women have AV node reentrant tachycardia and atrial tachycardia¹.
- Sinus Node Dysfunction (also called sick sinus syndrome) – a slow or irregular heart rhythm that originates in the SA node. The signal starts in the SA node but may be slow or delayed in progressing to the atria, causing a very slow or irregular heart beat.
- AV Nodal Re-entry Tachycardia (AVNRT) - a type of SVT with a fast heart rate that originates in the AV node. Instead of the AV node sending the impulse down one pathway, there are two pathways through the AV node. The impulses travel through one pathway as well as back up through the second pathway. This allows the impulses to travel around the AV node very quickly in a circular fashion, causing the heart to beat unusually fast.
- Long QT Syndrome - a QT interval longer than normal. This increases the risk for life-threatening forms of ventricular tachycardia.
- Postural Orthostatic Tachycardia Syndrome (POTS) - a condition that affects 500,000 Americans, primarily women. Those with POTS have an abnormal response to change in position, related to the autonomic nervous system, causing drop in blood pressure, raise in heart rate and sometimes syncope (passing out), dizziness or lightheadedness².
These arrhythmias occur more often in men, but may present differently in women:
- Atrial Fibrillation - one of the most common irregular heart rhythms. It is a rapid irregular heart rhythm originating in the atria. Men have atrial fibrillation more often than women. Atrial fibrillation can be associated with other types of heart disease. Women are more likely to have atrial fibrillation associated with valve disease, while men more often have atrial fibrillation associated with coronary artery disease. The incidence of atrial fibrillation increases in both men and women with age, and when they also have hypertension and diabetes. The Copenhagen Heart Study showed that women with atrial fibrillation had an increased risk for stroke and cardiovascular death as compared to men. This is particularly true in women who have atrial fibrillation and are older than age 75 ³ ⁴. Women who have paroxysmal atrial fibrillation, a type of atrial fibrillation that is intermittent (or comes and goes), may have a faster heart rate response than men, and tend to have longer episodes ⁵.
- Sudden Cardiac Death is a sudden, unexpected death caused by loss of heart function (sudden cardiac arrest). Sudden cardiac death (SCD) occurs less frequently in women, but is still related to about 400,000 deaths per year in women. The Nurses’ Health Study showed that while the majority of women who had SCD had no prior history of cardiovascular disease before death, they had at least one cardiac risk factor (smoking, hypertension and diabetes had the greatest impact). Family history also played a role in increased risk if one parent died of heart disease before age 60. The study also showed that as with men, the majority of SCD in women was related to an abnormality of the heart rhythm (88%) 5-7. This reinforces the need for careful screening of heart disease risk factors in women and managing these concerns even without symptoms present.
- Michael J. Porter, MD, Joseph B. Morton, MBBS, Russell Denman, MBBS, Albert C. Lin, MD, Sean Tierney, MD, Peter A. Santucci, MD, John J. Cai, MD, Nathaniel Madsen, MD, David J. Wilber, MD. Influence of age and gender on the mechanism of supraventricular tachycardia. Heart Rhythm 1:4. October, 2004, pp: 393-396.
- National Dysautonomia Research Foundation, www.ndrf.org/orthostat.htm.
- Kael WB, Wolf PA, Benjamin EJ, Levy D Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol. 1998 Oct 16;82(8A):2N-9N.
- Friberg J. Comparison of the impact of atrial fibrillation on the risk of stroke and cardiovascular death in women versus men (The Copenhagen City
- Hnatkova K, Waktare JE, Murgatroyd FD, Guo X, Camm AJ, Malik M. Age and gender influences on rate and duration of paroxysmal atrial fibrillation. Pacing Clin Electrophysiol. 1998 Nov;21(11 Pt 2):2455-8.
- American Heart Association Heart Disease and Stroke Statistics 2012 Update.
- Christine M. Albert, Claudia U. Chae, Francine Grodstein, Lynda M. Rose, Kathryn M. Rexrode, Jeremy N. Ruskin, Meir J. Stampfer, and JoAnn E. Manson. Prospective Study of Sudden Cardiac Death Among Women in the United States. Circulation, Apr 2003; 107: 2096 – 2101.
Symptoms and Causes
Symptoms of Irregular Heart Rhythms
An arrhythmia may be "silent" and not cause any symptoms. A doctor can detect an irregular heartbeat during an examination by taking your pulse, listening to your heart or performing diagnostic tests.
If symptoms occur, they may include:
- Palpitations – a feeling of skipped heart beats, fluttering, "flip-flops" or feeling that the heart is "running away"
- Pounding in the chest
- Dizziness or feeling light-headed
- Shortness of breath
- Chest discomfort
- Weakness or fatigue (feeling very tired)
Symptoms of palpitations represent 15-25 percent of all the symptoms reported by female heart patients. They are associated with:
- Premenstrual syndrome
- Perimenopausal period
When palpitations are present, the doctor begins his or her evaluation by looking for underlying heart disease. The importance of palpitations and the need for treatment is determined by the presence of underlying heart disease, the type of irregular heart beats that are occurring and other symptoms that are present.
Hormones and Irregular Heart Beats
Estrogen and progesterone levels rise and fall in women with a normal menstrual cycle during the days of the month. The rise of progesterone and the fall of estrogen correspond with:
- More frequent episodes of supraventricular tachycardia (SVT)
- More symptoms associated with SVT
- SVT of longer duration¹
During perimenopause (the time period before menopause), there is a marked decrease in ovarian estrogen production. This is associated with an increase in heart rate (sinus tachycardia) and an increased frequency in palpitations and non-threatening arrhythmias, such as premature ventricular contractions or PVCs.
Menopause causes a further decline in estrogen as the menstrual cycle stops. This time period is associated with irregular heart beats, palpitations, spasmodic chest pain and nightmares in women 40 -64 years old².
The Heart and Estrogen/Progestin Replacement Study (HERS) found no benefit in the use of hormone replacement therapy to reduce cardiovascular events, and hormone replacement therapy may even increase the risk of thromboembolism (blood clot) during the first year³. HRT is also associated with lengthening the QT interval [link to the explanation above], although the relevance of this finding is not known⁴. On the other hand, HRT may decrease palpitations and other symptoms such as hot flashes, insomnia, and sweating. Therefore, it may be considered a treatment option in low risk female patients to relieve symptoms of palpitations.
- Rosano GM, Leonardo F, Sarrel PM, Beale CM, De Luca F, Collins P. Cyclical variation in paroxysmal supraventricular tachycardia in women. Lancet. 1996 Mar 23;347(9004):786-8.
- Asplund R, Aberg HE Nightmares, cardiac symptoms and the menopause. *Climacteric*. 2003 Dec;6(4):314-20.
- Grady D, Herrington D, Bittner V, Blumenthal R, Davidson M, Hlatky M, Hsia J, Hulley S, Herd A, Khan S, Newby LK, Waters D, Vittinghoff E, Wenger N; HERS Research Group. Cardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II). *JAMA*. 2002;288:49-57.
- Gokce M, Karahan B, Yilmaz R, Orem C, Erdol C, Ozdemir S. Long term effects of hormone replacement therapy on heart rate variability, QT interval, QT dispersion and frequencies of arrhythmia. *Int J Cardiol*. 2005 Mar 30;99(3):373-9.
Arrhythmias & Pregnancy
Premature atrial beats occur in about 50 percent of women during pregnancy, although most are harmless and do not last¹. While sustained arrhythmia is somewhat rare, for those who have supraventricular tachycardia or paroxysmal SVT, the symptoms are worsened in 20 percent of cases¹. Symptoms of SVT may include shortness of breath, palpitations, and dizziness². Arrhythmias may occur more frequently during pregnancy due to changes in hormones, changes in associated hemodynamic, hormonal and autonomic changes and changes in circulating blood volume, sleep, and emotion during pregnancy.
Women who have had congenital heart defects repaired have an increased risk of arrhythmias during pregnancy. In 27 women who had repaired congenital heart defects and 29 pregnancies, SVT occurred in 15, ventricular tachycardia in nine, high </ grade heart block in four and sick sinus syndrome in three women³.
Arrhythmias in pregnancy are treated conservatively. After determining the type of arrhythmia, the physician will evaluate for underlying causes. If symptoms are minimal, rest and vagal maneuvers may be used to help slow the heart rate. Vagal maneuvers include carotid massage applying ice to the face, and the Valsalva maneuver, which is the most successful in stopping tachycardias⁴. The Valsalva maneuver involves a person exhaling forcibly with a closed glottis (the windpipe) so that no air exits through the mouth or nose as, for example, in strenuous coughing, straining during a bowel movement or lifting a heavy weight.
When the arrhythmia causes symptoms or a drop in blood pressure, antiarrhythmic medications may be used. No anti-arrhythmic medication is completely safe during pregnancy; therefore medications are avoided during the first trimester if possible to limit risk to the fetus. Drugs with the longest safety record should be tried first. Propranolol, metoprolol, digoxin, and adenosine have been tested and shown to be well tolerated and safe during the second and third trimester⁵.
Cardioversion is safe during all trimesters of pregnancy and can be used if necessary¹. In addition, women who have an ICD who become pregnant do not have an increased risk for ICD discharges or ICD complications. A woman who has an ICD can safely become pregnant unless she has an underlying heart condition that would increase health risks during pregnancy⁶.
- Blomstrom-Lundqvist C, Scheinman MM, et. al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias – executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). Circulation. 2003 Oct 14;108(15):1871-909.
- K. Robins\ and G. Lyons. Supraventricular tachycardia in pregnancy. _British Journal of Anaesthesia*, 2004, Vol. 92, No. 1 140-143._
- Tateno S, Niwa K, Nakazawa M, Akagi T, Shinohara T, Usda T; A Study Group for Arrhythmia Late after Surgery for Congenital Heart Disease (ALTAS-CHD). Circ J. 2003 Dec;67(12):992-7.
- Zu-Chi Wen, MD; Shih-Ann Chen, MD; Ching-Tai Tai, MD; Chern-En Chiang, MD; Chuen-Wang Chiou, MD; Mau-Song Chang, MD. Electrophysiological Mechanisms and Determinants of Vagal Maneuvers for Termination of Paroxysmal Supraventricular Tachycardia Circulation. 1998;98:2716-2723.
- Ferrero S, Colombo BM, Ragni N Maternal arrhythmias during pregnancy. Arch Gynecol Obstet. 2004 May;269(4):244-53.
- Natale A, Davidson T, Geiger MJ, Newby K. Implantable cardioverter-defibrillators and pregnancy: a safe combination? Circulation. 1997 Nov 4;96(9):2808-12.
Diagnosis and Tests
How are arrhythmias diagnosed?
If you have symptoms of an arrhythmia, you should make an appointment with a cardiologist. You may want to choose an electrophysiologist, a cardiologist who has received additional specialized training in the diagnosis and treatment of heart rhythm disorders.
After evaluating your medical history and discussing your symptoms, a physical exam will be performed. The cardiologist also may perform a variety of diagnostic tests to help confirm the presence of an arrhythmia and determine its causes.
Some tests that may be done to confirm the presence of an irregular heart rhythm include:
Management and Treatment
Management of Irregular Heart Rhythms in Women
Treatment options include:
Medications – antiarrhythmic drugs are medications used to convert the arrhythmia to normal sinus rhythm or to prevent arrhythmia. Other medications may include heart-rate control drugs; anticoagulant or antiplatelet drugs such as warfarin (a "blood thinner") or aspirin, which reduce the risk of blood clots or stroke.
Concerns for women: Because women have a longer QT interval than men. some medications that are used in men to treat irregular heart rhythms prolong the QT interval even more. These medications include Quinidine, Sotalol, Dofetilide, and Amiodarone. These medications may increase a woman's risk of developing a life-threatening arrhythmia (torsades de pointes) more than in men who take these medications. Women who take these medications should follow their’ doctor’s and dietitian’s dietary guidelines for potassium and avoid becoming low in potassium, which enhances the arrhythmia affect¹.
The biggest concern for all patients with atrial fibrillation is preventing blood clots or stroke. Warfarin (also called Coumadin) is most often used to prevent strokes in patients. According to The Canadian Registry of Atrial Fibrillation (CARAF), women were half as likely to be prescribed warfarin as compared to men, although they would benefit from it as much².
Lifestyle changes– arrhythmias may be related to certain lifestyle factors. Here are some ways to change these factors:
- If you smoke, stop. Learn More
- Limit your intake of alcohol. Learn More
- Limit or stop using caffeine. Some people are sensitive to caffeine and may notice more symptoms when using caffeinated products (such as tea, coffee, colas, chocolate and some over-the-counter medications).
- Avoid certain stimulants. Beware of stimulants used in cough and cold medications and herbal or nutritional supplements. Some of these substances contain ingredients that cause irregular heart rhythms. Read the label and ask your doctor or pharmacist what medication would be best for you.
Invasive Therapies – the following invasive therapies may be used to treat or eliminate irregular heart rhythms. Your doctor will discuss the benefits and risks of these therapies and whether they are appropriate treatments for your condition.
- Electrical cardioversion – in patients with persistent arrhythmias (such as atrial fibrillation), a normal rhythm may not be achieved with drug therapy alone. After administering a short-acting anesthesia, an electrical shock is delivered to your chest wall that synchronizes the heart and allows the normal rhythm to restart.
- Catheter ablation – during ablation, energy is delivered through a catheter to tiny areas of the heart muscle. This energy can either "disconnect" the pathway of the abnormal rhythm; block the abnormal pulses and promote normal conduction of impulses; or disconnect the electrical pathway between the atria and the ventricles.
- Pulmonary vein antrum isolation (PVI) – This procedure is used to treat atrial fibrillation. During PVI, special catheters are inserted into the heart (catheters are inserted into the right atrium and into the left atrium). Intracardiac echocardiography is used to visualize the left atrium during the procedure. One catheter in the left atrium is used to map or locate the abnormal impulses coming from the pulmonary veins. The other catheter is used to deliver the radiofrequency energy to ablate or create lesions outside the pulmonary veins. The procedure is repeated for all four pulmonary veins. The lesions form a circumferential scar around the pulmonary veins. The scar blocks any impulses firing from within the pulmonary veins, thereby "disconnecting" the pathway of the abnormal rhythm and potentially curing atrial fibrillation.
Electrical devices – a small device may be implanted under the skin that can detect an irregular heart rhythm and/or treat it. Your doctor will discuss the benefits and risks of implantable devices and whether they are an appropriate treatment for your condition.
- Permanent pacemaker – a device that sends small electrical impulses to the heart muscle to maintain a normal heart rate. The pacemaker has a pulse generator (which houses a battery and a tiny computer) and leads (wires) that send impulses from the pulse generator to the heart muscle, as well as sense the heart's electrical activity. Pacemakers are mostly used to prevent the heart from beating too slowly. Newer pacemakers have many sophisticated features that are designed to help with the management of arrhythmias, optimize heart-rate-related functions and improve synchronization.
- Implantable cardioverter-defibrillator (ICD) – a sophisticated electronic device used primarily to treat ventricular tachycardia and ventricular fibrillation, two life-threatening abnormal heart rhythms. The ICD constantly monitors the heart rhythm. When it detects a very fast, abnormal heart rhythm, it delivers energy to the heart muscle to cause the heart to beat in a normal rhythm again.
Heart surgery – The Maze, modified Maze, and minimally invasive ablation surgeries are used to correct atrial fibrillation that is not controlled with medications or non-surgical treatment methods. Arrhythmia surgery also may be recommended if you need surgery to correct other forms of heart disease (such as valve disease or coronary artery disease).
Treatment also includes regular follow-up with a physician. While women have specific concerns related to irregular heart rhythms, communication with your physician will ensure safe and effective treatment.
- Wolbrette D. Differences in the Proarrhythmic Potential of QT-prolonging Drugs. Current Women's Health Reports 2002, 2:105-109.
- Karin H. Humphries, Charles R. Kerr, Stuart J. Connolly, George Klein, John A. Boone, Martin Green, Robert Sheldon, Mario Talajic, Paul Dorian, and David Newman. New-Onset Atrial Fibrillation : Sex Differences in Presentation, Treatment, and Outcome. Circulation 2001 103: 2365 - 2370.
- Bailey MS, Curtis AB. The Effects of Hormones on Arrhythmias in Women. Current Women's Health Reports 2002, 2:83-88.
- Blacks, Women Less Likely to Get Implantable Defibrillators, www.dukenews.duke.edu/2000/11/blackwomenheartn17.html.
Doctors vary in quality due to differences in training and experience; hospitals differ in the number of services available. The more complex your medical problem, the greater these differences in quality become and the more they matter.
Clearly, the doctor and hospital that you choose for complex, specialized medical care will have a direct impact on how well you do. To help you make this choice, please review our Miller Family Heart, Vascular & Thoracic Institute Outcomes.
Cleveland Clinic Heart, Vascular & Thoracic Institute Cardiologists and Surgeons
Choosing a doctor to treat your abnormal heart rhythm depends on where you are in your diagnosis and treatment. The following Heart, Vascular & Thoracic Institute Sections and Departments treat patients with Arrhythmias:
- Section of Electrophysiology and Pacing: cardiology evaluation for medical management or electrophysiology procedures or devices - Call Cardiology Appointments at toll-free 800.223.2273, extension 4-6697 or request an appointment online.
- Department of Thoracic and Cardiovascular Surgery: surgery evaluation for surgical treatment for atrial fibrillation, epicardial lead placement, and in some cases if necessary, lead and device implantation and removal. For more information, please contact us.
- MyConsult Online Second Opinion Service.
The Heart, Vascular & Thoracic Institute has specialized centers to treat certain populations of patients:
Learn more about experts who specialize in the diagnosis and treatment of arrhythmias
For younger patients with abnormal heart rhythms:
See About Us to learn more about the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute.
If you need more information, click here to contact us, chat online with a nurse or call the Miller Family Heart, Vascular & Thoracic Institute Resource & Information Nurse at 216.445.9288 or toll-free at 866.289.6911. We would be happy to help you.
Becoming a Patient
- Atrial Fibrillation
- Ventricular Tachycardia
- All Miller Family Heart, Vascular & Thoracic Institute Treatment Guides
Diagnostic tests are used to diagnose your abnormal heartbeat and the most effective treatment method.
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- Visit Health Essentials - Read articles on rhythm disorders and healthy living on Health Essentials
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- Zipes, Douglas et al. Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines*, *J Am Coll Cardiol* 2006 48: e247-346.
- Heart Rhythm Society. "Heart Rhythm Disorders." Retrieved on March 1, 2011, from HRS website: https://www.hrsonline.org/patient-resources.
- Heart Rhythm Society. "Skipped Heartbeats." Retrieved on March 1, 2011, from HRS website: https://www.hrsonline.org/skipped-beats.
- The Merck Manuals Online Medical Library. "Ventricular Premature Beats (VPB)." Retrieved on March 1, 2011, from Merck Manuals website: www.merckmanuals.com/home/heart-and-blood-vessel-disorders/abnormal-heart-rhythms/ventricular-premature-beats.
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