Extrasystole - Symptoms and Factors

Introduction

Extrasystole is often a benign alteration of the heart rhythm. This is an early-onset pulsating contraction of the heart, which the affected individual can perceive to be an abnormal contraction, an extra or irregular heartbeat in comparison to the normal heartbeat, but which are detected and typified accurately only by instrumental examinations.

What Is an Extrasystole?

Extrasystoles are the most common form of cardiac arrhythmias. Extrasystoles are highly periodic in completely healthy people and patients with underlying heart or other pathological conditions. However, in the majority of cases, it is not a concerning and pathological disorder.

Physiologically, the heartbeat begins from the sine-atrial node (SA node), located in the upper part of the right atrium (one of the four chambers in the heart) and situated close to the upper hollow vein. SA node is the electrical control unit that starts the electrical impulse passing first through the atria and then through the ventricles (lower chambers of the heart), making the heart contract, allowing pumping of the blood into the body (systole indicates heart contraction, while diastole is its relaxation).

However, in the case of extrasystoles, that stimulus to contraction does not originate from the SA node, instead is localized elsewhere (atria, ventricles, atrioventricular junction), which interferes with the normal conduction of the electrical impulse. This ectopic impulse emerges at any stage of the cardiac cycle. It often modifies the ventricular diastole duration, which consequently may cause a cardiac output reduction, especially when the extrasystoles are frequent or repetitive.

There are different names depending on the origin of the stimulus that leads to an extrasystole heartbeat-

• An atrial extrasystole is when the stimulus comes from the atrial musculature.

• A ventricular extrasystole is when it comes from the ventricular musculature.

• An atrioventricular extrasystole or nodal junctional is when the stimulus comes from the atrioventricular node.

What Are the Symptoms of Extrasystoles?

• The altered pulsations can be spontaneous or frequent, with a manifestation that follows certain regularity. However, the affected individuals with extrasystole do not always feel these abnormal contractions because the condition is often asymptomatic. The affected individuals do not feel most of the extrasystoles, especially when isolated and infrequent.

• Symptomatic patients, instead, may have the sensation of a more intense heartbeat or a missing heartbeat, or there may be a feeling of flapping wings in the chest at the heart level, a sort of a stop to the heartbeat, or a plunge of the heart.

• If otherwise, the extrasystoles are repetitive (and occur in pairs or triplets, or alternate with the normal rhythm that determines a bi, tri, or quadruple rhythm) or occur frequently and last longer, the heart rhythm gets modified. The patient often feels it as palpitations that have an accelerated or irregular heart rhythm.

• In a few cases, however, the symptoms become more critical, mainly if associated with prolonged tachycardia leading to shortness of breath (dyspnea), dizziness, and increased fatigue (asthenia).

• In the case of benign extrasystole, the signs and symptoms tend to get worse at rest, sometimes, especially at night or after meals, and may disappear with physical exercise. However, in those instances where they increase with physical activity, they often indicate a more critical pathology. Therefore, they may require pharmacological therapies or interventions that aim to treat the underlying disease. For this reason, it would be essential to describe the symptoms in detail during the cardiological examination to define the form of this arrhythmia. However, apart from this, instrumental examinations are also necessary.

How to Diagnose Extrasystoles?

The most correct examination the cardiologist requires for diagnosing extrasystoles is the dynamic electrocardiogram. It records the heart rate for 24 hours, which allows one to count the number of irregular heartbeats, listing them according to their origin, and especially evaluating their frequency and repetitiveness compared to regular heartbeats and their appearance or reduction based on regular activities (work, sports, relaxation, rest, meals) and the sleep-wake cycle.

In case of further doubts that may be detected, it is possible to request the color doppler echocardiogram to evaluate the cardiac structure better and investigate the possibility of the presence of a congenital type of structural pathologies of the heart or acquired over the years and the stress test that allows recording the electrical activity of the heart by asking the patient to walk on the treadmill or ride a bike.

If the extrasystole decreases or disappears during exercise, it is usually not considered severe. But, conversely, if exercise increases or leads to extrasystolic heartbeats, it is possible that the heart will be fatigued pathologically, and it will be crucial to continue with more detailed or invasive examinations such as cardiac MRI (magnetic resonance imaging) or CT (computed tomography), or coronagraphy (radiography of coronary arteries).

What Are the Factors Affecting Extrasystoles?

Extrasystole can occur at any age. But the probability of its appearance increases with age. In a young individual with a healthy heart with no pathology, extrasystole often correlates with a functional disorder. It can be associated with excessive consumption of smoke, caffeine, carbonated or alcoholic drinks, abusive substances, some medicines (Digoxin, Aminophylline, tricyclic antidepressants), and stress (physical and mental). Fever, excessive anxiety, or extreme sports can also become triggers. In other cases, extrasystolic beats can occur due to a deficiency of magnesium, calcium, and especially potassium in the blood or due to an excess of calcium. Rest, correcting these behaviors causes the disappearance of extrasystole.

The extrasystole form of arrhythmia can also indicate other conditions that do not affect the heart, such as-

• Anemia.

• Thyroid disorders.

• Untreated arterial hypertension.

• Gastroesophageal reflux.

• Other digestive and intestinal disorders, such as constipation and gallstones.

However, numerous heart diseases are associated with extrasystole-

• Heart failure.

• Myocardial infarction (blockage of blood flow to the heart muscle).

• Valvular heart disease (damaged or diseased heart valve).

• Inflammation of the heart (myocarditis, endocarditis, pericarditis).

• Hypertrophic obstructive heart disease (thickening of the heart muscles).

• Diseases of the cardiac conduction system.

What Is the Treatment of Extrasystole?

Most patients with extrasystole, but otherwise healthy, do not require any therapy because they are benign and caused due to non-pathological conditions (anxiety, stress, digestive difficulties, sleep deprivation). However, decreasing the most common triggering factors, such as caffeine, nicotine, drugs, or excessive sports, can undoubtedly be helpful and sometimes essential to reduce the frequency regardless of the symptoms. In addition, many patients benefit significantly from lifestyle interventions, a healthy diet, and physical activity that is not excessively intense.

In some patients, when the symptoms become remarkable, some drugs may be used to slow down the heartbeat. Usually, these drugs are beta-blockers, given in low doses, or only anxiolytic drugs, which are quite effective in reducing the symptoms due to stress and fear.

In addition, relaxation techniques such as yoga or pilates, in the mildest forms, or antidepressant drugs and psychotherapy in the most severe conditions, can also reduce the symptoms and frequency of heart rhythm changes.

If, on the other hand, extrasystoles are related to non-cardiac diseases, for example, in anemia, hyperthyroidism, or digestive disorders, the treatment involves treating the underlying condition. However, in the presence of heart disease, extrasystole can lead to even more severe arrhythmias, so it may be important to use antiarrhythmic drugs, beta-blockers, calcium channel blockers, or Amiodarone in more complex cases.

When it is impossible to get a satisfactory result from the drugs, and it is important to treat the underlying heart disease, more invasive interventions are considered, such as valve replacement, radiofrequency ablation, and pacemaker implantation.

Conclusion

Extrasystoles are abnormal or extra heartbeats caused by stress, anxiety, and other non-pathological factors or due to some underlying cardiac or other diseases. It may be benign and without any symptoms or sometimes may be quite bothersome, requiring appropriate treatment. Lifestyle changes, diet modifications, and physical exercise may help achieve the desired result.