Arrhythmias

Overview: Arrhythmias

• Cardiac arrhythmias are slow (brady), fast (tachy), or irregu lar heart rhythm disturbances (ectopy, atrial fibrillation, and others). Arrhythmias may be a normal phenomenon related In change in autonomic tone, examples include sinus arrhythmia, sinus bradycardia, and sinus tachycardia.

• Arrhythmias should be evaluated and treated for interrelated reasons: (1) to eliminate symptoms, (2) to prevent imminent death and hemodynamic collapse, and (3) to offset long-term risk of serious symptoms and death.

• This chapter focuses on an approach to evaluate and treat arrhythmias by using an integrative approach.

• Common arrhythmias encountered in an office-based setting include atrial premature beats, ventricular premature beats, bradycardias, supraventricular tachycardia, non-sustained ventricular tachycardia, atrial fibrillation, and follow-up of already treated sustained ventricular tachycardia or ventricular fibrillation.

• Potentially symptomatic and dangerous (potentially life-threatening) arrhythmias that require evaluation for possible acute and chronic therapy include (1) sustained ventricular tachycardia in the setting of heart disease, (2) ventricular fibrillation (cardiac arrest), (3) atrial fibrillation, (4) supraventricular tachycardia, (5) sinus bradycardia (and pauses), and (6) atrioventricular (AV) block. Junctional rhythm.

• AV dissociation, and ectopic beats are common, may cause concern, and may require special attention, further evaluation, and therapy.

• These latter arrhythmias are generally not serious enough to require long-term aggressive treatment unless they are associated with severe symptoms.

Important Points to Consider

• Gastric distention from large meals, excessive caffeine, alcohol, high levels of sodium, trans fats, severe fluctuations in blood sugar levels, and possibly food allergies are potential dietary triggers of cardiac arrhythmias.

• A balanced diet low in fat and high in roughage that will lead to a moderate level of blood sugar and as little stress as possible on the gastrointestinal tract may improve the arrhythmias.

• For dosing omega-3 fatty acids, educate the patient to read labels. If you are recommending 1000mg of omega-3 fatty acids, the user needs to look at the amount of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) per serving size. If the label notes 300 mg of EPA and 200mg of DHA per two capsules (serving size), the patient would need to take four capsules daily to obtain 1000 mg of omega-3 fatty acids.

• The risk of proarhythmias from medication is greatest in those who need the most protection, specifically those patients with depressed left ventricular function with an ejection fraction less than 30%.

Prevention Prescription

• Avoid arrhythmia triggers if identified and definable (e.g., excess caffeine intake).

• Encourage regular aerobic exercise as long as it does not trigger arrhythmias.

• Urge risk factor reduction to prevent the development of structural heart disease (treatment of hypercholesterolemia, hypertension, smoking, excess ethanol intake).

• Moderate balanced caloric intake and maintenance of appropriate weight.

• Prevent stress. Incorporate meditation, yoga, and bioenergy techniques.

• Maintain a regular sleep-wake cycle with at least 7 to8 hours of sleep nightly. ■Consider supplementing with 1 to 2 g of fish oil and encourage two to three servings of fish each week.

• Avoid the use of drugs or supplements that stimulate or mimic the effect of catecholamines (e.g., over-the-counter decongestants, ephedra [Ma Huang], caffeine).

Integrative therapeutics review

The treatment of arrhythmias cannot be easily standardized and does not fit into any clearly defined algorithmic pathway. The reason for this is the diverse presentations of arrhythmias, the complexity of management, the great span of problems ranging from completely benign to clearly life-threatening, the lack of randomized controlled clinical data in some instances, the difficulty in diagnosing problems, and the overlap with many other syndromes. Despite these caveats, some rational commonsense recommendations can be set forth to manage patients who have suspected cardiac arrhythmias.

For Patients With Palpitations

• Diagnosis is crucial, and arrhythmias can range from sinus rhythm to various types of ectopy to supraventricular or ventricular tachycardia.

• If no arrhythmia is documented, consider anxiety or panic attacks and treat accordingly.

• Encourage stress reduction techniques such as meditation and yoga.

• For Patients With Symptomatic Ectopy or Premature Ventricular Contractions

Lifestyle

• Determine the severity of the symptoms and their relation to the arrhythmia. Assess underlying conditions.

• Determine the risk to the patient.

• For proven benign ectopy, discuss the risks of drug therapy and suggest alternatives first.

Nutrition

• Eliminate dietary or other apparent triggers (caffeine, alcohol, trans-fatty foods, blood glucose fluctuations).

Mind-Body Therapy

• Promote mind-body interventions such as meditation, yoga, Reiki, or qi gong.

• Counsel the patient about the benign nature of the condition. Patients who understand will be able to tolerate the arrhythmia better.

Exercise

• Determine the relation to exercise, and consider a tailored exercise program.

Supplements and Botanicals

• Suggest omega-3 fatty acids: 2 to 3 g/day of eicosapentaenoic acid plus docosahexaenoic acid essential fatty acids

• Magnesium supplementation: 300 to 1000 mg daily

• Consider herbal approaches: motherwort, 4 to 5 g of dried above-ground parts daily

• Consider carnitine: 3g daily, and then coenzyme Q10: 100 to 300 mg daily with a meal

Pharmaceuticals

• Drug therapy: only if resistant to foregoing measures

• Beta blockade (titrated upward): consider extended-release metoprolol (Toprol XL), 50, 100, or 200 mg daily; or atenolol, 50 to 100 mg daily

• Calcium channel blockers (diltiazem or verapamil): 120 to 360 mg/daily

• Antiarrhythmic drugs: used as last resort (if no structural heart disease, flecainide, propafenone. sotalol are the first choices; then amiodarone, but only in resistant, highly symptomatic cases, risks may outweigh benefits)

Ablation Therapy

• Suggest ablative therapy for motivated patients willing to take the excess risk. (Counsel patients. that symptoms are benign.)

• For Patient With Paroxysmal Atrial Fibrillation

Lifestyle and Risk Factors

• Correlate symptoms with the arrhythmia. Determine the presence of underlying conditions, including hyperthyroidism.

• Assess the risk to the patient and the need for rate control, anticoagulation, and maintenance of sinus rhythm.

Nutrition

• Determine triggers, if possible. If a relationship is determined, eliminate caffeine, alcohol, and any potentially offending drug.

• If arrhythmia occurs at night, consider changes in diet (no large meals causing gastric distention).

Exercise

• If arrhythmia is exercise related, consider an exercise program.

Mind-Body Therapy

• Promote mind-body interventions such as relaxation techniques.

• Counsel patients and educate them about the disease process.

Acupuncture

• Suggest acupuncture (not well tested but perhaps effective).

Supplements and Botanicals

• Omega-3 fatty acids: 1 to 2 g of fish oil daily Magnesium supplementation: 300 to 1000mg daily

• Hawthorn berry: 160 to 900 mg daily

• Motherwort: 4 to 5g daily

• Coenzyme Q10: 100 to 300 mg daily with a meal

Pharmaceuticals

• Beta blockade (to control rhythm and rate): see earlier for dosage

• Calcium channel blockade (to control rate, diltiazem or verapamil): 120 to 360 mg daily

• Digoxin (little effect, but may help in combination with a beta blocker and is safe if used carefully at proper doses)

• Antiarrhythmic drugs depend on the patient and the conditions. The risk-to-benefit ratio is complex and depends on other diagnosed conditions, symptoms, and antiarrhythmic drugs. Amiodarone is the most effective drug but has the greatest risk of side effects. Propafenone and flecainide can triple the risk of death in patients with underlying heart disease and are contraindicated in patients with coronary disease or impaired ventricular function.

Ablation Therapy

• Ablation of the pulmonary veins or parts of the left atrium

• Ablation of the atrioventricular node with a pacemaker (patient remains in atrial fibrillation) not completely effective

• Ablation of other inciting arrhythmias

Key Web Sources

• http://www. mdcalc.com/chads2-score-for-atrial fibrillation-stroke-risk

• http://www.surgicalaudit.com/riskcalc.asp

• http://hp2010.nhlbihin.net/atpiii/

• http://www.heartmath.com; and Stress Eraser: http://stresseraser.com

• http://www.fammed.wisc.edu/sites/default/files//webfm-uploads/documents/outreach/im/hand-out omega3 fats_patient.pdf