At The Forefront Live: Understanding and Treating Irregular Heartbeat
February 6, 2020
Heart rhythm disorders, arrhythmias, and irregular heartbeats are a source of trouble for millions of Americans. Atrial fibrillation, also called AFib, is the most common type of abnormal heart rhythm. Symptoms can include a rapid erratic pulse and this can lead to higher risk for clots, stroke, or heart failure. Today on At the Forefront Live, we'll talk about AFib and other heart rhythm disorders. We'll also learn about the signs, and symptoms, and possible cures. And we'll take your questions for our doctors. That's coming up right now on At the Forefront Live.
And welcome now to Forefront Live. I want to remind our viewers, we'll take your questions for our experts. Just type them in the comments section. We'll get to as many as possible over the next half hour. Also, please remember that today's program is not designed to take the place of an actual visit with your physician. And we're very happy today, we've got Dr. Rod Tung and Dr. Andrew Beaser joining us to talk a little bit about just all kinds of matters of the heart. It is heart month, so this is fitting. And if we can, Dr. Tung we're going to start with you, have you just tell us a little bit about what you do here at UChicago Medicine.
My name is Roderick Tung and I am a cardiac physiologist, which is someone that specializes in all heart rhythm disorders, from fast to slow. And I am the director of our Center for Rhythmic Care.
Great. And Dr. Beaser, what do you do here? I'm also an electrophysiologist, focusing on patients with heart rhythm disorders. And as I told my son, I take people whose heart rates are too slow, make them can go faster or take people of hearts that are too fast and make them go slower.
Great. So let's you start off with some of the basics. And again, want to remind our viewers, just type your questions in-- we'll take as many as possible over the next half hour. But let's start with what does an electrophysiologist actually do. What is your job?
I think the most important thing is that we really are diagnosticians. So we're all trained in internal medicine and then we go through general cardiology training. And then those that are passionate about the electrical nature of the heart go into electrophysiology. And that really is essentially trying to diagnose people's irregular heart rhythms-- their palpitations, their abnormal pounding, the fasts, the slows, as Dr. Beaser is talking about.
And then we prescribe different types of therapies, which are in the form of medications or procedural therapies. And we've actually brought a bunch of toys and things to show everyone the type of gadgets and tricks that we have to be able to restore heart rhythms.
I love it when the doctors do show and tell, so I'm glad you guys brought this stuff with it. It'll be interesting as we move through the half hour. Dr. Beaser, talk to us a little bit about-- you mentioned fast and slow. Both are issues. What do people experience when they're going through a situation like this? What would it feel like?
Well, the first thing I'd say is everybody feels symptoms differently. And for slow heart rate, usually, people feel dizzy, fatigued, maybe lightheaded, feel like they're going to pass out. Sometimes, they do pass out. For folks with fast heartbeats, palpitations would be the main thing. Rapid heartbeats, pounding in the chest, irregularity in the chest. Some sort of vague discomfort sometimes is all that they feel. Difficulty breathing, chest pain. All of these things can be seen. and so it's our job to decipher when that's related to the heart rhythm or related to other problems, potentially.
I remember talking with someone that had AFib surgery done or work done. And it was interesting, because he had mentioned that after he had the procedure done, that it felt so quiet to him. And he hadn't realized that just the physical feeling would change so much. So I thought that was fascinating.
Well, it is interesting because our bodies-- the human body is so resilient in terms of its physiology that we actually get used to sometimes, different disease conditions or disease states. And sometimes, a patient will be in an abnormal rhythm in the beginning and then we find that they get desensitized to it. They learn to live their life with, actually, a decreased quality of life. And then they say, well, I actually feel OK. And then you take it away and there's something magical where they say wow, I didn't realize I could feel that much better. And I think that's part of the art of medicine is that we're really trying to try to decipher distinguish those that actually have symptoms and those that don't have symptoms at all.
So we're already getting questions from our viewers, which is fantastic. And the first one is, do other conditions like sleep apnea affect arrhythmias?
Very much so. Yeah, we're learning more and more about the association between sleep apnea and many arrhythmias, but in particular, atrial fibrillation. So it is becoming our practice to take anybody with atrial fibrillation and assess for sleep apnea. And treatment of sleep apnea is critical for treating atrial fibrillation and for actually being able to control it.
You know, I think a lot of people have the-- I'm not wearing my Apple Watch today, but a lot of people have the Apple Watches and things like that, where they will look at their heart rates and they'll track their sleeping rate. And does anybody even know what to look for, though? Because I look at mine and I look at the numbers, but it means very little to me.
Yeah, I think you're referring to this historical Apple heart study that was published in The New England Journal by some friends and colleagues, Turakhia and Marco Perez-- close friends and congratulations to them. They basically started looking at patients that enrolled themselves digitally and they got almost a half a million people with Apple watches to enroll themselves through the Apple website and then tracked their heart rates. And it was really the first time that we could actually do a clinical study with digital enrollment. That's a virtual-based cardiac monitoring.
And they actually found that a lot of them-- one in 200-- because it's a lot of people are healthy that have these Apple Watches-- but one in 200 actually had irregularities identified. And then they went on to try to correlate that to see if it was real. And they actually found that about a third of them, they could detect that atrial fibrillation with pretty good accuracy.
So it's not perfect, but it is a nice way to use technology. And I think that whole advent of wearables has really changed the way that we're seeing our field, heart rhythm disorders, kind of integrate in a normal human, a normal American's daily life.
We have the ultimate wearables right there in front of you. So if you could kind of explain to us what some of these are, that'd be great.
This is a good segue into the monitoring that we have available. We've had these since before the Apple Watch. And often, if somebody comes in with abnormalities that they find in their Apple Watch, we will confirm it with a device like this. So this is a implantable loop recorder. And it sits just on the chest-- I'm sorry, I moved it there. But just on the chest under the skin. And allows us to monitor for up to two or three years to identify if there is any arrhythmias.
And here's an example of, right next to it, what it used to look like and what they look like now. And we're miniaturizing everything. So it's going to become easier and easier.
Yeah, we tell people this is almost like sci-fi where we can inject a microchip underneath your skin, because that's really what this is. It's an injectable. It's just like a dermatology procedure if you were to have a mole removed, they give you a little bit of local injection in the skin. And this can monitor your heart rhythm every beat up to about three years. And all that information gets downloaded to our office on a daily basis.
So some patients really feel a lot of security by knowing that they're being tracked all the time. So this is a really nice breakthrough.
And that's not like major surgery to have something like that. Like you mentioned, you're in and out, and it's just right into the skin. You don't even know it's there.
It's just like a pellet that's injected underneath the skin.
So what are the other items that we're seeing there?
Yeah, so in terms of device-based therapy, we have two devices right here. I don't know if you can zoom in on this, but this is a defibrillator. This is used for the treatment of rapid heartbeats to prevent somebody from passing out or even passing away as a result of an arrhythmia. That can be used to shock the heart back into a normal rhythm. Lifesaving.
The next device here is a little bit smaller, as you can see. That's a pacemaker. And that is used for people with slow heartbeats. Allows them to have generally a better quality of life, avoid those dizzy symptoms we were talking about earlier, and allow them to live the way that they want to.
The pacemaker will be attached to a lead. And this is an example of a lead that we use. And this goes from the chest where it's inserted, all the way down into the heart and attaches to the heart muscle. And allows us to collect information and pace the heart as needed.
And to further miniaturize everything, as that's a pacemaker with a long lead, this one right next to it is called a leadless pacemaker. And this will be the entire pacemaker. This sits in the bottom right chamber of the heart, the right ventricle, and it watches for slowing of the heart rate or pauses, and kicks in when it needs to. Really quite a revolutionary device.
And just for the patients and those watching is patients don't really understand this pacemaker. This is the battery. Essentially, we call that the generator. And that sits here. And then it connects to the lead or the wire. It goes into a little vein underneath the collarbone. And then that would come wrap in here, drop into the hear, and then this little small screw goes into it. So that's really how it sits into it.
And life with a pacemaker is completely normal. There's nothing you can't do. You can skydive, you can bungee jump. You can go through airports. We usually just tell people to tell people you have a pacemaker so if the metal detector goes off, but there's no reason to fear cell phones, microwaves, anything like that. There's no limitations.
So we have more questions from our viewers, which is fantastic. What causes irregular heartbeats and can you develop it later in life, even if you have not any problems before?
There's so many causes of irregular heartbeat. Some patients actually have a normal heartbeat, but they sense it. And that's very common in patients either with anxiety. Some patients at night feel it more. And why? Because their cell phones are off, everything's quiet. And in particular, if you lay on your left side, you will often feel your normal heartbeat sensation, and that actually is alarming.
So sometimes, it's normal. Sometimes, it's just a single skipped a beat. We call those PBCs or PACs, which is a premature atrial or ventricular top chamber bottom chamber twitch. And that's very common. And some people will feel a twitch and some people feel that their heart rate takes a little bit of a pause before the next bit comes back, and will feel that.
And then we have the whole category of sustained arrhythmias. And when we say sustained, that means they last for more than 30 seconds, a minute, five minutes. And that's like an episode. And those episodes could be anything from the top chamber, bottom chamber, either twitching too fast consecutively. Or sometimes, we see the heart electricity get caught into a little short circuit or a little loop. And those can be a little flutters or something called ventricular tachycardia.
So there's so many different causes of it. And that's why I was saying is the first important thing is just the appropriate diagnosis. And that's why it's important to see a heart rhythm specialist to get you the right diagnosis first.
And if you occasionally just have a little skip, you probably don't need to get terribly worried about that. But if you are concerned, see your physician.
Great. So what is a normal heart rate?
So normal heart rate is defined as 60 beats per minute up to 100 beats per minute. And it's a range because everybody's a little bit different. And also, our heart rates are going to change based on what we're doing. So when you're sitting and relaxing, reading a book at the end of the day, it's going to be closer to 60. When you're racing to catch that bus so you're not late to work, it's going to be more like 100 beats per minute or even higher. And that can be totally normal.
Sometimes, people have a resting heart rate that is a little bit high-- maybe over 100 beats per minute. And that's something that we can sometimes investigate further to see if that's an arrhythmia or just a normal variant.
And when you are at sleep at night, do you expect it to go down 10 beats, 20 beats?
Variable. But as we see for our patients who are in the hospital and we're able to monitor them, often, the heart rate goes below 60. And again, that's considered normal. I guess I'd also highlight athletes often have heart rates less than 60 beats per minute at rest or even when they're starting to exert themselves. And again, that can be considered normal.
So what are some other signs of heart rhythm disorders?
It comes in all shapes and forms. And what's also fascinating is given the exact same type of a rhythm problem, patients will have completely different symptoms. And that's known in general, even for women with heart awareness, is women have different symptoms than men. Surprise, surprise-- different biology. But it's just that some patients will come in with chest pressure with a heart attack, some patients will feel nausea.
And the same is true for atrial fibrillation. Some patients just come in with fatigue and they say, you know what, I just can't walk as far as I used to be able to walk. And some people will say, I feel my heart pound every single beat. And many times, they'll believe that they don't have symptoms if they don't feel their heart pound, but it could really be the early onset of something like congestive heart failure that the arrhythmia is triggering that's actually their symptom. So everything from feeling nothing to fatigue, shortness of breath, actually, heart pounding, and then actually, a true faint, is the whole spectrum of what we see with arrhythmias.
So the treatments-- also, there's a huge spectrum there. Because you mentioned as we started to show, anything from medication to various procedures. And I'm curious-- we had some video. And if we could roll some of that, if you can talk us through this, and tell us what we're seeing. And I believe this is you, actually.
Yeah. I didn't know you guys were spying on us in our arrhythmia technology suite. So this is our tech suite that we use to showcase a lot of different technologies. We're one of the few places, actually, in the country that has every available mapping system. So this is a mapping system. And when we go into the heart, we don't actually open up the chest-- that's what our cardiac surgeons do. We do everything through minimally invasive procedures.
So what you're seeing there is us steering a little steerable wheel catheter. It's done through a very small IV port in the vein of the leg called a femoral vein. And all of these are done by a percutaneous technique-- and percutaneous means through the skin-- where there's no cutting, there's no sewing, there's no stitches.
Then like a pilot's cockpit, what you're seeing there is that we've got all these different screens where we're actually looking at the real time X-ray of the heart-- how it's beating, how quickly, the vital signs. And then this mapping system is essentially using a contact GPS system, where we without seeing the heart, without knowing where we are, creates a shell. It's a geometry to say, oh, we're virtually in this. We create the shell. And then everywhere we touch has an electrical signal that we can record.
And if we're trying to find an arrhythmia, it's like a game of hot and cold. As you get closer and closer to it, you can see that the electricity gets earlier and earlier. So it's kind of like dropping a pebble into a pond and you see the ripple effect where it comes out. And when you get to the center or the source of the problem, we can actually tell by how the electricity is measured from different areas. So we're looking at the electrical currents in the heart.
Interesting. And when you find the arrhythmia or if you get close, what do you do then?
Perfect. Actually, this is right there where we feel like we're right on the spot. So I don't know if you can cue to this, but we've actually brought in ablation catheter. Because the word ablation is out there all the time, and I think patients and just Americans don't typically see what ablation is. But essentially, what we're doing is we're cauterizing and burning the local heart tissue. But to give you a sense of how small the tool is that we're using, it's actually three millimeters, just the tip of it.
So this is the steerable catheter. It's long because it goes up the leg. We advance it up. And if you look really closely here, you can see that we can use this handle and steer it side to side, give it a torque, and move it back and forth with areas of the heart. And then once we're on the area that we believe is where the problem is, then we can deliver a very focused, very precise radio frequency customization. So it's a thermal heat source. And zap that one spot. And our goal is to try to zap as little as we need to-- just get whatever to correct the problem.
And the effect on the patient is immediate, is it correct?
Yeah, typically, it depends on the type of arrhythmia. With atrial fibrillation, it's more of a treatment. That we treat a wide area like an exterminator goes into treating a pest problem. They kind of do a spray in the usual corners all four corners of the room. And with some very precise arrhythmias where it's a small little circuit, we can see that the arrhythmia goes away, and it stops dead in its tracks when we're zapping it, and burning it. And that's the most fulfilling for us.
And there's this mantra in electrophysiology that ablation is salvation. And it really can be for the physician, for the patient, for the patient's family.
You guys could get t-shirts made.
And you do that work and then you also work with some of our other cardiologists and surgeons on a variety of treatments for the heart. It's really fascinating the work that you guys do. What are some of the other things? How does that work out?
It's a great collaboration with the other cardiologists, interventional cardiologists, cardiac surgeons. Dr. Tung has been part of the group pioneering a treatment of a PVC, which we mentioned earlier, coming from a very difficult spot in the heart to reach. And combining our therapies with Dr. Balkhy, one of the robotic cardiac surgeons here, to pinpoint this area in a way that was never able to be done before. So it's these kind of collaborations that really allow us to tackle these problems.
Interesting. So we talk about the heart beating too fast. I think that's generally what people think of. But you can also have the heart beat too slow. What causes that? Is that same thing and how do you fix it?
Sometimes, that can be normal aging and kind of beyond normal aging. it can get too slow with age. There can be infections and other problems that can do it like Lyme disease, for example, although that's more of an issue in other parts of the country. And other types of cardiomyopathies, heart diseases, can lead to a slowing of the heart rate as well.
But it's our job to figure out where the problem occurs in the heart. And often, it's these pacemakers that allow us to treat that. At this point for somebody at home there isn't really a pill that they can take to make the heart rate go faster. And that's where the pacemaker comes in.
Interesting. So if you do have the irregular heartbeat, can it point to more serious health conditions or other health conditions?
Sometimes, the irregularity is actually the symptom of an underlying problem. And one of the principles of diagnosing arrhythmias is to really determine if the patient has a what we call structurally normal heart. That means everything else is fine-- this is an electrical problem. And that's why we'll often do diagnostics with echocardiography, doing an [? aorta ?] ultrasound to see. And also, sometimes, even cardiac MRI. We're a real MRI specialty center. An MRI gives you the highest resolution of the heart muscle, what's going on inside-- the heart valves, the heart function. So we always want to understand that this is a pure electrical problem or this is associated with something else.
And then what's interesting is this relationship with heart failure and arrhythmias is many patients with heartfelt will get secondary arrhythmias. But there's a greater appreciation now that the arrhythmia itself, if it's untreated, and sustained, and you're in it all the time, can actually lead to heart failure. And one of the studies or scientific experiments that we do to create heart failure models is actually, when you pace animals for four weeks at a time, and you pace them a little too fast-- 120, 130 beats per minute, it actually starts weakening the heart muscle.
So we do know that tachycardia, which is fast heart rhythms and heart rates, can actually create heart failure. And those are fully reversible many times with just the correction of the electrical problem.
What age range do you see most of your patients? Are these adults that you see or does this happen in peds in all or children?
As adult physicians, we generally see folks 18 to whenever, any age. But we occasionally we'll have some teenagers come through our clinic as well. There are pediatric cardiologists who do what we do. They treat slightly different type of a arrhythmias. Some of the things that we see in folks with heart failure who are 80 years old, they're not seeing quite as often, sure. But any age. Arrhythmia can affect anybody of any age.
Interesting. So if somebody thinks that they have symptoms of an arrhythmia, what do they need to do? Is that something that's an emergency? That they dial 9-1-1 or just make an appointment with their physician? What do you do?
Well, as you have mentioned, the occasional skip, where it's very transient, it's not something that continues to bother, is usually something more innocent and benign. The stuff that's really a warning sign is fainting. If you lose consciousness, then that's something that needs to be taken very seriously. And I think that's when you needed further evaluation. So we're really concerned about the pre-faint and the fainting spells that could really signify something that's a little bit more malignant or dangerous.
So we hear about stress tests and EKG and things like that. And a lot of times people think about that if they're maybe having a heart attack. What exactly is that? How does it? Work and when do you use tools like that?
So an EKG is the most basic thing that we do, but it's sometimes the most telling thing that we do.
Is that the first step when you see someone?
It's usually the first step, yeah, after talking to the patient and understanding about what their symptoms are. But EKG is pretty simple, non-invasive. 12 stickers get placed on the body and mostly in the chest-- on the arms and legs, as well. And it gives us an electrical recording of what's happening in the heart. Tells us where the impulses are coming from, whether they're conducting through the heart the way they're supposed to, or if there's any abnormalities. This is the first step to try and diagnose these problems. And usually will tell us if it's a slow heart rate problem, fast heart rate problem problem, and will help guide our future diagnostic testing and therapies.
And the stress test itself?
Stress test is actually that plus a stress, which is usually exercise, if we can get people to run on a treadmill. For those that can't, there's medications we can give to simulate stress. And we can see if there's a change in heart function, and heart rate, heart rhythm with exercise or with stress. And that can also give us some clues as to where the abnormality is or if there's some underlying problem that might require some attention.
And it's also important to emphasize many patients, they'll say, well, is there a family history of something? And everyone calls a heart attack-- it's a very generic term. And that's where it's really important when you really are looking into your family history to say, well, is this someone that actually had an electrical problem? Was it actually a real myocardial infarction, which is when the blood flow gets blocked? And that's more of a plumbing issue than an electrical issue.
And we always talk about general contractors or general cardiologists. We're the electricians of the heart, the plumbers are the [INAUDIBLE] cardiologists. And then you've got the pump specialists, which are the heart failure cardiomyopathy doctors. And I think it's really important to understand the inner relationship of it, but which one is really the primary problem.
So do arrhythmias run in families? Is this something that's hereditary?
They certainly can. Atrial fibrillation is not commonly an inherited condition. That's something that we see-- it's a disease of actually, aging. And until we can reverse aging, we're probably never going to be able to cure atrial fibrillation. But it's more prevalent with every decade of life, affecting 3 million Americans. And estimated worldwide is probably about 35 million. So it's the most common sustained arrhythmia we see worldwide in adults.
But that's usually not related to genetics, where there are some that we see in the early teenage years, where patients will actually inherit an abnormality of the ion channels. Where the normal currents of the heart actually get imbalanced and that actually creates arrhythmia. So that's usually a different presentation when they come in, really, as teenagers and early on.
And it's incredible, because I've seen the suite, which is actually fairly close to where we are right now, it's pretty fascinating watch you work in there because you do some amazing things. And of course, we showed the video of it earlier. But the key to this is people don't have to suffer through this. These are mainly fixable items.
A typical arrhythmia where that is very much the story is SVT. People can suffer for decades with these symptoms. They've learned to cope with them. They've learned how to bear down or blow through a straw to get rid of it. And then with one procedure, that's gone and they never have it again. And so yeah, people can feel better.
Can you repeat for us, what does SVT stand for?
Thank you, yeah. Supraventricular tachycardia. So it's generally a fast heartbeat, either a twitch or a little short circuit, as Dr. Tung was mentioning earlier, from the upper chambers of the heart. A nuisance rhythm. Annoying and uncomfortable.
I had no idea that people used methods like that to stop it. Is that common?
And it's important to historically highlight the fact that we've really been doing this catheter volition-- this stuff where we go in through the leg and zap these little spots-- really, since the early '90s. So when you look at this exciting field of arrhythmias, it's Dylan it's infancy and we're making discoveries every single day. But to be able to do what we do, it used to require open heart surgery in the 1970s and '80s. So now with this ability, patients are going home the same day. And it's crazy to say, I had a heart procedure, and go home the same day. And that's what we're doing. And again, there's no cutting, there's no sewing, there's no stitches.
And on a personal note, I had an SVT, the supraventricular tachycardia, which was a little short circuit in the middle of the heart-- very common in healthy patients. I was diagnosed with that as a teenager when I was an undergrad. And that's what sparked my interest. And that's kind of why I've devoted my life to the ablation aspect of thing.
That's a great story, because it's a very personal connection for you. So I'm going to have you guys do a little bit of myth busting. I'm going to throw a couple of curves at you. You're smart guys, you can handle this, I'm sure. Couple of things. So you mentioned a second ago about bearing down-- or I've also heard the old driver-- if you cough if you think you're having a heart attack, that's going to do something. True or false?
I'm going to go with false on that one.
But there's part truth in the sense that coughing can trigger something.
See, I'm glad we did this.
These are called Vagal maneuvers. So bearing down like you're having a bowel movement, coughing can trigger something similar. Can actually trigger the heart rate to slow down and try to break some of these arrhythmias. So partly true, partly false.
The other one, this is from my grandmother from years ago.
That must be true.
Oh, it's got to be true, yeah. That's before the internet. She used to tell me never sleep on your left side because that was hard on your heart.
As somebody who sleeps on my stomach and left side, I hope that's out. I don't think that's true. Although with some conditions, it can be more uncomfortable to sleep on the left side. So there might be some truth to it in that regard as well.
Awesome. Well, you guys have been fantastic. This is very interesting and very enlightening. Appreciate it you being on.
Thank you very much for having us.
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Our website is UChicagoMedicine.org. If you need an appointment, please give us a call at 888-824-0200. Thanks again for being with us today and hope you have a great week.
The heart’s electrical system regulates all four chambers of the heart to maintain a steady rhythm. A normal resting heart rate is between 60 and 100 beats a minute, but some people experience a fluttering in the chest, a racing heartbeat or a slow heartbeat.
Heart rhythm specialists Roderick Tung, MD, and Andrew Beaser, MD, diagnosis and management of heart rhythm disorders, or arrhythmias.
Andrew Beaser, MD
Andrew Beaser, MD, specializes in cardiac electrophysiology, which is the diagnosis and management of heart rhythm disorders (arrhythmias). Dr. Beaser treats a wide range of arrhythmias and performs catheter ablation for basic and complex conditions, such as atrial fibrillation, supraventricular tachycardia and ventricular tachycardia.Learn more about Dr. Beaser
Roderick Tung, MD
Roderick Tung, MD, is an internationally renowned cardiologist and specialist in cardiac electrophysiology. Dr. Tung is an expert in the management of heart rhythm disorders (arrhythmias), with a particular focus on advanced therapies for atrial fibrillation and ventricular arrhythmias.