Diplomate, Board Certification of Emergency Medicine
We will continue on our discussion of rhythm disturbances. We
discussed the situation in young people, and indeed,
electrophysiologists can map the electrical centers in the
heart and actually burn out the offending center. Not easy
work and you should consider a good cardiologist in a good
center to do this work.
Atrial fibrillation is an extremely common rhythm. Here the
top chamber of the heart does not give its usual kick of all
its blood to the lower chamber but instead there is
disorganized electrical activity. Instead of blood being
kicked into the lower chamber, it just falls in by gravity.
This rhythm is very uncomfortable, and also has the
additional danger of blood moving slowly and sitting, which
can predispose to clots. These clots can than travel to the
brain and cause a stroke.
All patients with this rhythm should have it slowed down.
Whether or not it should be converted to a regular rhythm
depends. All patients deserve at least one chance at it. It
can be done through electrical means, which is the most
effective. However many drugs can be used to convert and
preserve the rhythm. One thing must be made clear: if
conversion is to be done, it must be done within 48 hours of
the start of this rhythm, before clots start to form. Once 48
hours have passed, three weeks of anticoagulation must be
done. This means taking drugs that inhibit the blood's
ability to clot, as a heart that converts the rhythm to
normal may now throw clots that have formed during the bad
rhythm phase into the periphery. People who have the problem
of this rhythm on and off should take aspirin if they are
young, coumadin if they are old but stable (coumadin is a
stronger inhibitor of clotting) and if the patient is
unstable on their feet or falls often -- then nothing at
all.
The fear is that the danger of bleeding from falling is worse
than the danger of stroke. In any case, one can live with
this rhythm but must be on guard for stroke.
Other rhythms in the top part of the heart are rarer. People
who smoke and develop lung disease can have MAT. This is an
unusual, uncomfortable rhythm that can race and the only
treatment is to deal with the lung problem.
The problems start when the lower chamber interrupts the
normal rhythm. This can be by a strange occasional flutter in
the heart or a run of these beats that can cause loss of
consciousness. Sometimes the bottom chamber can beat by
itself without control from the upper chamber. These people
need pacemakers. We will discuss this next week.
A message from GlaxoSmithKline, sponsor of this
column. Ventolin remains the treatment standard for
asthma and has been so for more than thirty years. But
prevention requires steroids and these are best given by the
inhalation route. Glaxo's product is Flixotide and is very
effective. This one- two punch can make breathing a
breeze.
