Table Of Content39790_FMxx_Pass3.qxd 2/28/06 10:29 AM Page i
You and Your Arrhythmia:
A Guide to Heart Rhythm
Problems for Patients
and Their Families
John A. Kastor, MD
Professor of Medicine
University of Maryland
School of Medicine
39790_FMxx_Pass3.qxd 2/28/06 10:29 AM Page ii
World Headquarters
Jones and Bartlett Jones and Bartlett Jones and Bartlett
Publishers Publishers Canada Publishers International
40 Tall Pine Drive 6339 Ormindale Way Barb House, Barb Mews
Sudbury, MA 01776 Mississauga, Ontario L5V 1J2 London W6 7PA
978-443-5000 CANADA UK
[email protected]
www.jbpub.com
Jones and Bartlett’s books and products are available through most bookstores and online
booksellers. To contact Jones and Bartlett Publishers directly, call 800-832-0034, fax 978-443-
8000, or visit our website, www.jbpub.com.
Substantial discounts on bulk quantities of Jones and Bartlett’s publications are available to
corporations, professional associations, and other qualified organizations. For details and spe-
cific discount information, contact the special sales department at Jones and Bartlett via the
above contact information or send an email to [email protected].
Copyright © 2006 by Jones and Bartlett Publishers, Inc.
All rights reserved. No part of the material protected by this copyright may be reproduced or
utilized in any form, electronic or mechanical, including photocopying, recording, or by any
information storage and retrieval system, without written permission from the copyright
owner.
Library of Congress Cataloging-in-Publication Data
Kastor, John A.
You and your arrhythmia : a guide to heart rhythm problems for patients and their families /
John A. Kastor.
p. cm.
Includes bibliographical references and index.
ISBN-13: 978-0-7637-3979-9 (pbk.)
ISBN-10: 0-7637-3979-0
1. Arrhythmia—Popular works. 2. Arrhythmia—Treatment—Popular works. I. Title.
RC685.A65K38 2006
616.1’28—dc22
2006002408
6048
Production Credits
Executive Publisher: Christopher Davis
Associate Editor: Kathy Richardson
Production Director: Amy Rose
Associate Production Editor: Kate Hennessy
Associate Marketing Manager: Laura Kavigian
V.P. of Manufacturing and Inventory Control: Therese Connell
Cover Design: Kristin E. Ohlin
Composition: Paw Print Media
Printing and Binding: Malloy, Inc.
Cover Printing: Malloy, Inc.
Printed in the United States of America
10 09 08 07 06 10 9 8 7 6 5 4 3 2 1
0533
39790_FMxx_Pass3.qxd 2/28/06 10:29 AM Page iii
Dedication
To my teachers, especially
Roman W. Desanctis and Saul J. Farber
39790_FMxx_Pass3.qxd 2/28/06 10:29 AM Page iv
39790_FMxx_Pass3.qxd 2/28/06 10:29 AM Page v
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
Glossary of Medical Terms and Definitions . . . . . . . . . . . .xiii
Part I How the Heart Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
1 The Heart as a Pump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
2 The Heart as an Electrical Organ . . . . . . . . . . . . . . . . . . . .7
Part II Patients and Their Arrhythmias . . . . . . . . . . . . . . . . . . . . . .9
3 Premature Beats in a Healthy Student . . . . . . . . . . . . .11
4 Atrial Fibrillation in a Medical Intern . . . . . . . . . . . . . .15
What Is Atrial Fibrillation? . . . . . . . . . . . . . . . . . . . . . . . . .16
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
5 Atrial Fibrillation in a Man with a Heart Murmur . . .21
Causes of Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . .22
Initial Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
More Trouble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
6 Supraventricular Tachycardia (SVT) in a Healthy
Young Woman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
v
39790_FMxx_Pass3.qxd 2/28/06 10:29 AM Page vi
vi Contents
History of Patients with
Supraventricular Tachycardia . . . . . . . . . . . . . . . . . . . .36
Symptoms Produced by SVT . . . . . . . . . . . . . . . . . . . . . . .37
Treatment—Physical Actions . . . . . . . . . . . . . . . . . . . . . . .38
Treatment: Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Treatment—Ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Wolff-Parkinson-White (WPW) Syndrome . . . . . . . . . . .42
7 Atrial Flutter in a 45-Year-Old Executive . . . . . . . . . . .43
Causes of Atrial Flutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45
8 Multifocal Atrial Tachycardia in a 75-Year-Old
Housewife with Emphysema and Diabetes . . . . . . . . .47
9 Ventricular Tachycardia in a Man with Coronary
Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
Implantable Cardioverter-Defibrillator . . . . . . . . . . . . . .52
Thumpversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
10 Ventricular Fibrillation Producing Cardiac Arrest . . .57
11 Heart Block in a 72-Year-Old Professor . . . . . . . . . . . .61
What Is Heart Block? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62
Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Causes of Heart Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67
Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68
12 Sick Sinus Syndrome and Carotid Sinus
Hypersensitivity in a 60-Year-Old Man . . . . . . . . . . . . .69
Causes of Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
Part III Treating Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75
13 Drugs Used to Treat Arrhythmias . . . . . . . . . . . . . . . . .77
Adenosine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77
Amiodarone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80
Beta-Adrenergic Blocking Drugs . . . . . . . . . . . . . . . . . . . .83
Calcium-Channel Blocking Drugs . . . . . . . . . . . . . . . . . .84
Propafenone (Rhythmol) . . . . . . . . . . . . . . . . . . . . . . . . . . .85
Ibutilide (Corvert) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .86
39790_FMxx_Pass3.qxd 2/28/06 10:29 AM Page vii
Contents vii
Sotalol (Betapace) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87
Other Antiarrhythmic Drugs . . . . . . . . . . . . . . . . . . . . . . .88
14 Devices Used to Treat Arrhythmias . . . . . . . . . . . . . . . .89
Pacemakers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89
Implantable Cardioverter Defibrillator . . . . . . . . . . . . . .90
Part IV The Electrocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . .93
15 The Machine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95
Ambulatory Electrocardiographic Recording . . . . . . . .97
Other Cardiology Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . .98
16 Electrocardiograms of Arrhythmias . . . . . . . . . . . . . . .99
Normal Sinus Rhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
Sinus Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
Sinus Bradycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100
Ventricular Premature Beat . . . . . . . . . . . . . . . . . . . . . . .100
Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101
Supraventricular Tachycardia (SVT) . . . . . . . . . . . . . . . .102
Wolff-Parkinson-White Syndrome
(W-P-W Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
Atrial Flutter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
Multifocal Atrial Tachycardia (MAT) . . . . . . . . . . . . . . .104
Ventricular Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . .104
Ventricular Fibrillation . . . . . . . . . . . . . . . . . . . . . . . . . . .105
Complete Heart Block . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
Sick Sinus Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106
Part V Historical Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .107
17 Michel Mirowski and the Implantable
Cardioverter-Defibrillator . . . . . . . . . . . . . . . . . . . . . . .109
Escape and Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113
Medical School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .116
Postgraduate Training . . . . . . . . . . . . . . . . . . . . . . . . . . . .118
Cardiologist in Israel . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
Back in Baltimore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .123
Designing the Defibrillator . . . . . . . . . . . . . . . . . . . . . . .125
Financing the Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127
39790_FMxx_Pass3.qxd 2/28/06 10:29 AM Page viii
viii Contents
Animal Studies, the Film . . . . . . . . . . . . . . . . . . . . . . . . .128
Ready for Humans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129
Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131
Family and Reputation . . . . . . . . . . . . . . . . . . . . . . . . . . .131
18 Wolff, Parkinson, and White . . . . . . . . . . . . . . . . . . . . .133
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139
39790_FMxx_Pass3.qxd 2/28/06 10:29 AM Page ix
Preface
Cardiac arrhythmias are among our most common afflictions. Usually
they have little clinical importance and present no risk to the life of
patients who have them. Occasionally, however, they can produce trou-
blesome symptoms and may even bring about the patient’s death.*
Arrhythmias produce rapid, slow, or irregular heartbeats of which
some patients may be acutely conscious, whereas others may be
unaware. Explaining what arrhythmias are and how doctors treat
them—when that is necessary—is the purpose of this book.
First I explain the anatomy and physiology of the heart, particularly
of the electrical components that give rise to arrhythmias.
Then I describe most of the arrhythmias that patients may
develop. Each chapter has been built around the experiences of a
patient for whom the author or one his colleagues has cared. In some
cases, I have changed the stories slightly to facilitate understanding
and to avoid confusing the picture with issues that the doctors might
have needed to consider but are unrelated to the topic being dis-
cussed. In the next section, I explain how cardiologists use drugs and
* For a more comprehensive discussion of the subject, some readers may want to con-
sult the author’s text Arrhythmias(Philadelphia, W.B. Saunders, 2000).
ix
