1. Which arrhythmia is present?
2. Does the arrhythmia cause symptoms?
3. Does the arrhythmia have prognostic significance?
4. Is the problem life-threatening?
5. Does the patient require hospital admission or extensive testing?
6. Is specialist consultation required, and, if so, how urgently?
7. Is treatment required?
Reasons for referral to a specialist
• Resuscitated ventricular fibrillation
• Sustained ventricular tachycardia
• Atrial fibrillation that is difficult to control or refractory to standard therapies
• Nonsustained ventricular tachycardia
• Symptomatic supraventricular tachycardia that is difficult to control
• Sinus bradycardia (sick sinus syndrome, tachy-brady syndrome)
• Second-degree atrioventricular block
• Unexplained ventricular ectopy in an athlete or in a symptomatic patient
• Syncope with a suspected arrhythmic mechanism
• Patients with devices (pacemakers, implantable defibrillators) who are unstable
• Uncontrolled rhythm problems
When a surface electrocardiogram is not sufficient, invasive studies can be useful: electrophysiological intracavitary study allows accurate mapping of arrhythmias and of therapeutic maneuvers of ablation. Defibrillators and pacemakers have the ability to record arrhythmic events that can then be analyzed by a doctor.
The treatment of arrhythmias has become very complex and ranges from the use of some simple principles of lifestyle to specialist drug therapies and invasive catheter-based or surgical procedures. A detailed description of specific treatments for these conditions is not within the scope of this chapter. According to Graboys (cited in Devries and Dalen ), key concepts to keep in mind in arrhythmia management are the following: “try simple measures first before considering drug therapy. Be the patient’s advocate. Minimize tests, especially invasive tests in the elderly. Maintain a sense of humor and optimism.” Let us focus on some concepts that underlie an integrative approach to patients with arrhythmias (Fig. 18.1).
Arrhythmias could develop from changes in diet or from comorbid eating disorders. Gastric distension following a large meal can trigger a vagally mediated atrial fibrillation, hypotension, and bradycardia . Excessive caffeine, theophylline, and theobromine present in coffee, tea, and chocolate may cause ectopic beats [8–13]; alcohol may determine atrial fibrillation and ventricular ectopy [14–17], high levels of sodium (strengthens the effects of catecholamines favoring ventricular ectopy [18–23]), trans-fats (contained in doughnuts, fried foods, and artificial cheese such as in processed pizza) [24, 25], and severe fluctuations in blood sugar levels; food allergies  are also potential dietary triggers of cardiac arrhythmias.
Omega-3 fatty acids, albeit without proven anti-arrhythmic effects , improve outcomes [28, 29], especially in combination with a low dose of alcohol consumption [30–32].
Active ingredients found in some plants, such as ephedra, ambrotose, or ginkgo, can even cause lethal arrhythmias [3, 33, 34].
Diet is an important factor to be considered in patients receiving warfarin to optimize the values of the International Normalized Ratio, as there are many drug, food, and herbal interactions to control.
Finally, many arrhythmias are caused by dehydration . Thus, the patient’s hydration status should be checked, as many people (and especially those with a heart disease or taking diuretics) are chronically dehydrated.
Supplementation with coenzyme Q10 (100–300 = m/day) determines a reduction of ventricular and atrial extrasystoles and atrial fibrillation paroxysms .
L -carnitine (3 g/day), improving energy processes in mitochondria and thus the myocardial performance, may be useful in preventing some atrial and ventricular arrhythmias; the precise mechanisms by which this occurs have not yet been well clarified [36–39].
Supplementation of calcium and magnesium has an anti-arrhythmic effect: in fact, the magnesium, in addition to slowing the atrioventricular conduction, acts as a “membrane stabilizer,” decreasing the arrhythmic mechanism of “triggered activity” and the number of arrhythmic episodes related to it , and decreasing the risk for sudden death . Data concerning magnesium and atrial fibrillation are conflicting [41, 42].
A key electrolyte in arrhythmic processes is potassium and its values must be kept at adequate and physiological levels for both preventive and therapeutic goals . Particular attention should be paid to patients with a possible physiological and anatomical substrate for arrhythmias (such as ischemic heart disease or long QT syndrome) and those who take medications that could lead to a potassium deficiency (such as diuretics) .
Although high copper values are associated with worsening atherosclerosis, its supplementation (4 mg/day) could decrease ventricular extrasystoles . Excess zinc determines copper deficiency and worsens arrhythmic activity, in addition to a selenium deficiency. In the latter case, there is no evidence for selenium supplementation with an anti-arrhythmic result [18, 43].
Omega-3 fatty acids have an anti-arrhythmic effect [44–48] (especially on premature ventricular beats [49, 50]), because they affect the activities of calcium and potassium ion channels . This effect improves outcomes [52–54] in patients with heart disease (especially higher risk patients ), decreases the risk of sudden death in the case of ischemic heart disease [51, 56], and tends to reduce defibrillator shocks in patients with implantable cardioverter defibrillators (ICDs) . Administration of omega-3 may be useful  in the case of atrial fibrillation [59–63] (especially after cardiac surgery, albeit with some conflicting evidence [64, 65]) and in the treatment of depression [66, 67], which is an important prognostic factor in cases of heart attack and a trigger for arrhythmias [68–70]. Omega-3 fatty acids are available in various forms, not only fish oil . Some studies related to the use of omega-3 have failed to demonstrate an effect, probably because patients were already receiving optimal drug therapy .
We must pay close attention to certain toxins present in some supplements such as dioxins, polychlorinated biphenyls, polybrominated diphenyl ethers, and chlorinated pesticides .
Regular aerobic exercise with moderate effort is good for the cardiovascular system and this also applies to the treatment of rhythm disorders . Indeed, exercise increases vagal tone and decreases the circulating levels of catecholamines and sensitivity to their effect. Attention should be paid to patients with malignant arrhythmias that could be aggravated by exercise. These patients should be monitored by specialists.
18.6 Mind–Body Therapy and Acupuncture
As William Harvey wrote in 1628 : “every affection of the mind that is attended with either pain or pleasure, hope or fear, is the cause of an agitation whose influence extends to the heart”. Perceived stress is a key factor in triggering the cascade of psycho-neuro-endocrine immunitary sequelae that can cause several adverse cardiovascular events, including some rhythm disorders [68–70].
As suggested by Graboys : “I frequently ask the patient precisely when his or her symptoms began which may allow us to identify a ‘trigger’ which defines and unlocks the problem without the use of medications.”
Mind–body techniques, and in particular, the practice of yoga and meditation, play a well-positioned role in the treatment of arrhythmias [82–84], as they are able to favorably alter the autonomic function of the practitioners , reducing the risk of ventricular fibrillation in high-risk patients or the number of arrhythmias in ICD carriers [84, 86–89]. The practice of yoga is very useful in the treatment of atrial fibrillation (especially if paroxysmal), as it reduces the paroxysms considerably [84, 90].
Even biofeedback [91–95] and psychosocial therapy  appear to reduce the number, frequency, and severity of palpitations related to arrhythmias, increase the heart rate variability, and decrease the risk of arrhythmic death.
18.7 Phytomedicine: A Perspective Solution for Arrhythmias
Many of the anti-arrhythmic drugs commonly in use are derived from plants. To cite a few examples: quinidine from cinchona bark; lidocaine, amiodarone from khellin present in Ammi visnaga, or digoxin from foxglove .
In nature, there are other phytoelements with anti-arrhythmic properties.
Ciwujia or Siberian ginseng (Acanthopanax senticosus Harms) extract reduces malignant arrhythmias (ventricular tachycardia and fibrillation) [101, 102].
Angelica and Ginkgo biloba may protect against arrhythmias occurring during myocardial ischemia and reperfusion [103, 104]. Licorice root has an anti-arrhythmic effect [105, 106].
Traditionally, motherwort (4–5 g/day) is useful for treating palpitations, because its principles (bufenolide, glycosides (stachydrine), and alkaloids) have a mild beta-blocking effect . However, no randomized controlled trials have been performed using motherwort.
Khella (Ammi visnaga), in addition to having anti-angina properties, has significant anti-arrhythmic effects, as it is the original substance from which a very potent anti-arrhythmic drug, amiodarone, was derived [107–109].
Hyperoside (vitexin, rhamnose), rutin, and oligomeric procyanidins contained in hawthorn berries (160–900 mg in water–ethanol extract) can be used to treat atrial fibrillation , reducing the risk for sudden death, and helps to treat patients with heart failure .
Rhodiola produces some anti-arrhythmic effects , as it is able to increase the ventricular fibrillation threshold through the stimulation of kappa-opioid receptors  and by affecting intracellular calcium signaling .
The possibility of refractory ventricular tachycardia in the case of herbal aconite tea poisoning should be considered .
In the treatment of palpitations, herbs with a sedative effect can be useful (30 drops, 2–3 times daily, aqueous mixture of fluid extracts of Crataegus oxyacantha, Passiflora incarnata 25 mL in equal parts; or one tablet, three times daily of a mixture of Lavandula officinalis 50 mg, Valeriana officinalis 200 mg; Melissa officinalis as a mother tincture 20–30 drops 2–4 times a day, in the case of hyperthyroidism) .
Ethanol extracts of the plant Sophora flavescens Ait. reduce cardiac arrhythmias (ventricular tachycardia) induced by coronary artery ligation in rats, and by aconitine infusion in mice, suggesting their potential clinical use for anti-arrhythmic treatment .
Many other plants (garlic, agrimony, celery, ginger, berberine, corkwort, Stephania tetrandra root, astragalus, Fissistigma glaucescens, Xin Bao, Bu Xin, Yu Zhu, and Mai Dong), particularly used in the context of traditional Chinese medicine, possess anti-arrhythmic and cardioprotective activity, but there is a lack of scientific evidence for the reproducibility of their effects and their precise dosage to describe a potential use in the Western medical system.
Traditionally, the mild form of brady-arrhythmias can benefit from the use of coffee or dry extract of guarana (10% caffeine) 500 mg/tablets, 1–2 capsules before breakfast and lunch .
At the present time, however, the data are not definitive enough to recommend treatment with any of these herbal therapies for a specific form of arrhythmia.
18.8 Tricks of the Trade
Currently, natural remedies are effective in the management of palpitations related to stress and anxiety. In this scenario, it may be useful to resort to linden, valerian, or passionflower. It is possible to use the dietary supplement potassium-magnesium-bromelain mentioned in Chap. 17.
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