TESTS

I have been to the doctor because I was so worried about these rapid heartbeats that occurred. He has given me a little machine to record any attacks that I get in future. Can you tell me more about this please?

Because palpitations don't usually occur when you visit the doctor, a 24-hour ECG (see Chapter 2) is often used. This is like a 'Walkman' but it records your heartbeats instead of playing music. The digital card is replayed through a computer and we see the results in a matter of minutes. It does not record any sound so you need not worry that Big Brother is listening in!

You can use this machine at home so that the doctors can watch what your heart is doing during normal daily life. You will be asked to keep a diary and the recording will be checked for times when you felt palpitations or became dizzy.

Four electrodes are attached to your chest and fastened with wires to the recorder which is worn on a belt round your waist (see Figure 6.1). The monitor is quiet and you should not be inconvenienced. Whilst using the recorder, act normally and try to bring on the symptoms you have been having. You are not allowed to have a bath or shower without a special cover being used. You will be asked to return the recorder the next day so that we can analyse the recording to see if you need any special treatment. Sometimes we do several recordings over 2-5 days.

Figure 6.1 A mobile ECG recorder known as a Holter, about the size of a 'Walkman'

I think the machine that I am to be given is called an event recorder. Is this different to the 'Walkman'-type recorder?

This is a small machine which you put on your chest to record a palpitation as it happens. It is about the size of a mobile phone and can be carried easily. The palpitation is then decoded over the telephone or in the technicians' department, and printed out on an ECG. It is useful when attacks are infrequent but noticeable, and they have to be long enough for you to take action to record them. You will be shown how to use it by the technician at the outpatient department when you collect it.

There are now several recorders which you can activate yourself -some are very small so they are easy to live with. They store information which can then be downloaded and analysed on a computer. They are particularly useful when attacks are infrequent, and where a 24-hour ECG may miss them. Sometimes a device called a Reveal is inserted under the skin, under local anaesthetic. This is about the size of a PP3 battery and can be used to record infrequent episodes, being kept in place for up to a year.

An appointment has been made for me to go to hospital for electrophysiological (EPS) tests. What are these?

These are tests which have to be done in hospital, not at home. Pacemaker catheters (usually four) are passed via a vein at the top of your leg to the heart and the source of palpitations pinpointed and analysed with complex computers. It usually takes up to an hour but can take several hours; it generally needs to be done with X-ray guidance in the catheter laboratory. The only pain you should feel is the local anaesthetic in the groin, but as the doctor moves the catheters you may become aware of your palpitations as the doctor identifies them and tries to get them to occur again. It is usually done as a day case, or one night in hospital may be advised.

TREATMENT

I have a very stressful job and find that I get really nervous. My heart seems to miss a beat when I am stressed or anxious. Is there anything that can help me?

Missed beats usually respond to self-help, perhaps with a doctor's reassurance which might include taking an ECG at rest and recording the heartbeat for 24 hours (24-hour ECG see the section Tests above). A lot of people, who get palpitations like this, are young and under stress, and are helped by beta-blockers which block the stimulation of adrenaline and caffeine to the heart (see the question on beta-blockers in the section Risks of high blood pressure in Chapter 2). These can be used for a month while you try and change your lifestyle where possible, and then as required, for instance before a stressful meeting. Try not to drink too much coffee at meetings and change to decaffeinated-type drinks.

I am going for tests at the hospital next week for palpitations. Will I be offered any medication to treat irregular heartbeats?

It will depend on what type of palpitations that you are found to have. There are a large number of medications used to slow down fast heartbeats and to suppress extra beats.

• Digoxin is most often used to control atrial fibrillation (see below). Doses vary according to how old you are and how good your kidneys are. Your body gets rid of digoxin through your kidneys so, if the kidney function is not as good as it should be, digoxin will build up in the blood. Commonest side effects are loss of appetite, nausea and vomiting. Your doctor may check the level of digoxin in the blood 6 hours after you have taken it to make sure it is not too high or too low. If you get side effects, these will probably disappear if the dose is reduced. (See the section Treatment in Chapter 5.)

• Beta-blockers are also used for controlling palpitations. They also help angina, heart failure and high blood pressure; they are especially useful if you have more than one of these conditions. (See under Treatment in the Risks of high blood pressure section in Chapter 2.)

• The calcium antagonists, verapamil and diltiazem, are alternatives to beta-blockers for palpitations and, like beta-blockers, can be combined with digoxin.

Other more specific medications can be used to suppress extra beats and these include flecainide and amiodarone. These are powerful drugs, used if the simpler medications such as beta-blockers are not proving effective.

• Flecainide is effective in 30 minutes, so is often used as and when the attacks have to be stopped immediately. It is a very effective medication when taken on a regular daily basis by people whose lives are made a misery by troublesome palpitations, but it is unsafe to use it at all if you have heart failure or soon after a heart attack. It can cause nausea, dizziness, and unsteady feelings. It can be used just to stop an attack, known as 'pill in the pocket' so you carry it and use it when needed.

• Amiodarone is a life-saving medication for some but, because of its side effects, it is not normally used as a long-term treatment unless there is no alternative. It is very effective in the management of atrial fibrillation (see below), extra beats and dangerous palpitations, and it can be used when you have heart failure and after a heart attack. It takes some time to start working and can take a long time to leave the body. Side effects include sensitivity to sunlight, skin reactions, lung problems and disturbances of the thyroid gland and liver. You will need regular supervision so that the doctor can check for side effects. Amiodarone increases the action of warfarin so extra care is needed by your doctor to monitor the blood-thinning effects of warfarin, if you are taking this.

• Other drugs less frequently used and mainly alternatives to flecainide include disopyramide, propafenone and mexiletene.

All are effective drugs but side effects can be a problem. If you are prescribed any of these drugs, always read the package label and discuss the potential benefits and side effects with your doctor.