From pills to pacemakers — get your heart back on track

TREATMENT for heart rhythm problems has been transformed in recent years. Here, we talk to the experts for the latest thinking on the options you might be offered . . .

MEDICATION

Drugs are by far the most common treatment for the majority of heart rhythm problems.

Anti-arrhythmics are generally the first treatment that all people with arrhythmias are offered, because they can be started straight away and most abnormal heart rhythms respond to them, says Helen Williams, a consultant pharmacist for cardiovascular disease and spokesperson for the royal Pharmaceutical Society. BETA-BLOCKERS: Around 60 to 70 per cent of patients with atrial fibrillation are treated with beta- blockers, such as atenolol, bisoprolol and metoprolol, which helps to slow down the heart rate.

‘ Beta- blockers have a general slowing effect on metabolism and can cause lethargy, which can be more noticeable with the first few doses and then often settles down,’ says Helen Williams. CALCIUM CHANNEL BLOCKERS: These are given to about 40 per cent of atrial fibrillation patients and reduce the amount of calcium entering the cells of the heart and blood vessel walls — the muscular linings of heart muscle cells need calcium to contract.

Drugs such as diltiazem are used to control atrial fibrillation and other fast heart rhythms.

‘For most people, serious sideeffects are rare,’ says Dr Kevin O’Shaughnessy, an honorary consultant and senior lecturer in clinical pharmacology at Addenbrooke’s Hospital in Cambridge. ‘The most common side- effects are ankle swelling, flushing and palpitations.’

MEDICAL PROCEDURES

For those who have more serious types of arrhythmia, ‘interventional’ cardiology, as it’s known, may be necessary. CARDIOVERSION: This is carried out under general anaesthetic and involves stopping the heart momentarily with an electric current — the ‘ shock’ makes it spontaneously restart back in the normal heart rhythm. It is done by electrodes on sticky pads being placed on the chest.

‘This is usually more effective with people newly diagnosed with atrial fibrillation,’ explains Philippa Hobson, a senior cardiac nurse with the British Heart Foundation. ‘ It is very effective, but it won’t stop the problem returning.’

repeat cardioversion may be needed in more than 50 per cent of patients with persistent atrial fibrillation, according to a 2010 study in the International Journal of Clinical Practice.

‘The whole procedure takes around 20 minutes and it is performed under very controlled conditions,’ says Professor Chris Gale, a cardiologist at Nuffield Health York Hospital. ‘It does depend on the patient’s health, as someone with heart failure may not be suitable, but cardioversion shocks usually have less voltage than defibrillators carried by paramedics.

‘This is about 50-100 joules of energy, compared to 150 joules used in an emergency situation.’ CATHETER ABLATION: This is a treatment for atrial fibrillation and is the most common medical procedure for arrhythmias.

It involves thin tubes (called catheters) being passed into the heart through a vein or artery, starting at the groin or arm, and typically, heat is used to block the pathways of faulty electrical signals.

Cardiac nurse Philippa Hobson says: ‘Catheter ablation is a non- surgical procedure that is becoming the gold standard way to resolve heart rhythm problems — particularly atrial fibrillation — because it is minimally invasive and, unlike drug therapies, has few long-term side-effects.’ In most cases, the patient is awake, although sedated and with a local anaesthetic to help ease any discomfort. Ablation methods include applying radiofrequency energy, heat, or extreme cold (known as cryoablation), to destroy the abnormal tissue responsible for the heart arrhythmia or to block the faulty electrical signals. As cardiologist Dr Chris Pepper explains: ‘Ablation is often used for people with atrial fibrillation, but is also used for patients with supraventricular tachycardia [ an abnormally fast heartbeat at rest]. ‘Before we do the procedure for patients with supraventricular tachycardia (not necessary for patients with atrial fibrillation), we do an electrophysiology study — mapping out the heart

Ask your doctor whether you need to tell the DVLA about a heart rhythm problem. You may need to speak to your insurer, too

using electrodes. These are threaded through catheters to record electrical activity in the heart itself.

‘This allows us to see where the electrical supply is being disrupted or if you have extra electrical pathways in your heart that could be causing the abnormal heart rhythm.’ PACEMAKER: For decades, people with a slow heartbeat have benefited from implantable pacemakers.

The small electrical device, about the size of a matchbox, is placed under the skin near the collarbone on the left side of the chest, connected by thin wires to a battery slipped beneath the skin of the shoulder.

Typically, they work on demand, detecting if your heart has missed a beat. When it does, they send out electrical signals through wires at a steady rate, to trigger the heart to contract and produce a heartbeat. Most pacemakers are powered by a lithium battery, which lasts between six and ten years before it needs to be replaced.

‘New micro pacemakers, the size of a grain of rice, which cost about ten times as much as standard pacemakers, are now available on the NHS,’ says cardiologist Dr Pepper.

‘However, the National Institute for Health and Care Excellence (NICE) may not recommend them in future for most, which would be a shame.’

These new pacemakers are fitted into the muscular wall of the right upper chamber of the heart via a catheter, where they deliver regular electrical signals when needed.

Their miniaturised battery lasts for around 12 years — there is no need for wires to a battery pack implanted under the skin.

When the battery runs out, the pacemaker has to be removed and the battery replaced, though a Swiss company has developed a pacemaker based on a clockwork wristwatch, which is powered by motion of the heart.

‘These leadless pacemakers have many advantages, including their size and, therefore, a smaller operation, and a long battery life,’ says cardiologist Professor Gale. IMPLANTABLE CARDIOVERTER DEFIBRILLATORS: These are similar to pacemakers, but only send a larger, electrical shock to the heart if it slows to such an extent that it is likely to go into cardiac arrest.

The electrical shock is usually enough to reboot the heart and get it back to its proper rhythm.

Dr Pepper says: ‘These are useful after people have had heart attacks or significant heart damage and face cardiac arrest.’