Antiarrhythmic drugs are necessary evil, so how can we actually suspect arrhythmias earlier and diagnosed them early sir?
Very important point is getting the right history and the patient himself may complain of palpitations, uncomfortable feeling of heartbeat or the patients may complain of presyncope, dizziness or giddiness or some of them may actually fall down, so these are patients where you suspect that they could be having arrhythmias. In order to find out whether it is indeed an arrhythmia or not that may be very simple tools, getting an ECG done at the time of palpitations, but an ECG will record the rhythm only for half a minute or a minute or so. So the next step is doing a Holter which is a walkman like machine which is just attached on to the chest and it records the rhythm for 24 to 48 hours. If patients complain of symptoms which are less frequent, may be once a week or so, now a days we have something called an external loop recorder which is a patch which can be put on the chest and it records the rhythm for about a week. Some patients may be having symptoms which are rare, infrequent, but very serious and in those cases then we put an implantable loop recorder which is a small lighter like gadget which is implanted below the skin. In some patients it may just not be possible to record the arrhythmia in any possible way and in those cases then we would do an electrophysiology study. It is an invasive study, lasts about 15 to 20 minutes. We put in catheters through the groin into the heart and record the electrical signals. We can stimulate the heart or we can diagnose the arrhythmia and the wonderful thing about this is we can actually treat the arrhythmia and give a permanent cure by doing radiofrequency ablation at that time. Apart from all these which are the standard scientific ways and cardiac electrophysiology way of diagnosing and treating these arrhythmia, now a days we have smart phones which can come with certain apps and attachments. If the patient is having any problem, they can just put there fingers on it or keep it on the chest and the rhythm can be recorded. So the social media is invading into cardiology also and this is a simple way of diagnosing what the patient is suffering from.
That sounds very interesting and which arrhythmias are life saving so where we actually are feared that patient may end up.
Which arrhythmias are life-threatening? These are problems which often occur in patients who already suffered heart disease, myocardial infarction and heart attack and there LV function the pumping of the heart is low. In these patients, they may get ventricular tachycardia which are life-threatening and they can cause sudden cardiac death. There are other patients who have other forms of structural heart disease like dilated cardiomyopathy and having low pumping functions. If they get ventricular arrhythmias, they can cause sudden cardiac death. There is another subset of patients who have a normal heart, but may be suffering from electrical problems like WPW syndrome. If they get atrial fibrillation which is otherwise a fairly benign innocuous arrhythmia and if these patients get atrial fibrillation then they can get very fast ventricular rhythm and that can cause sudden cardiac death in some patients. So these are the various types of arrhythmias which can be life-threatening.
So do all arrhythmias need treatment and what are the drugs which are used?
Certain arrhythmias like premature atrial beats or premature ventricular beats especially in patients with normal heart need not be treated at all and the patients can just be reassured about the same. Certain arrhythmias may be nonsustained last for few seconds, come may be once a month or once a year they can be left alone. The patients who are suffering from frequent episodes of arrhythmias, they may be treated with medications or they can be advised an electrophysiology study and a curative radiofrequency ablation. There are few diseases in medicine where we can tell the patient okay you are cured of the problem and you never need to take a medicine again in your life and arrhythmia is one such problem where we can tell the patient that you can be cured of the problem and the patient never needs to take a medication. So there are certain antiarrhythmic drugs which can be given, some of them are fairly benign like beta-blockers which are fairly safe in almost all patients and they are protective for the patient also. The more classic antiarrhythmic drugs are what are called class 1 and class 3 agents, amiodarone or sotalol which are good, effective, but they have their own problems. They are double edged swords. They can create problems on their own.
So why are we considering antiarrhythmic drugs are necessary evil?
Yes, very good question and like I said certain arrhythmias can be life-threatening and we need to give antiarrhythmic drugs for these patients like post MI and LV dysfunction patients who have already got a defibrillator implant. If these patients get frequent ventricular arrhythmias, we may need to give them amiodarone or sotalol to decrease the burden of arrhythmias in these patients and to reduce the number of times the ICD needs to treat the arrhythmia, but the same drug amiodarone or sotalol can be proarrhythmic in certain situations and proarrhythmia that is a drug which is given to treat arrhythmia can itself precipitate life-threatening arrhythmias so that can be a big problem. Other issue was drugs like amiodarone can cause threshold toxicity so they get accumulated in the lipids and the fats and they can cause problems in the lungs, liver, skin and thyroid, so on one hand the antiarrhythmic drugs are necessary in certain subsets, on the other hand they have their own problems. It is a necessary evil that we have to live with.
So they are a double-edged swords.
Yes, but used judiciously by discerning clinicians, they are wonderful tools and they are wonderful to keep the problems under control.
Thanks, Dr. Naik for coming and joining us today and sharing your views on the topic. Thanks a lot.
Thank you very much, it was my pleasure.