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Key Clinical Updates in Disorders of Rate & Rhythm

Possible arrhythmia can be identified by optic sensors on wearable devices, such as smartwatches, with a positive predictive value for detection of atrial fibrillation of approximately 70%.

Abnormalities of cardiac rhythm and conduction can be symptomatic (syncope, near syncope, dizziness, fatigue, or palpitations) or asymptomatic. In addition, they can be lethal (sudden cardiac death) or dangerous to the extent that they reduce cardiac output, so that perfusion of the brain and myocardium is impaired. Stable supraventricular tachycardia (SVT) is generally well tolerated in patients without underlying heart disease but may lead to myocardial ischemia or heart failure in patients with coronary disease, valvular abnormalities, and systolic or diastolic myocardial dysfunction. Ventricular tachycardia, if prolonged, often results in hemodynamic compromise and may deteriorate into ventricular fibrillation if left untreated.

Whether slow heart rates produce symptoms at rest or with exertion depends on whether cerebral and peripheral perfusion can be maintained, which is generally a function of whether the patient is upright or supine and whether LV function is adequate to maintain stroke volume. If the heart rate abruptly slows, as with the onset of complete heart block or sinus arrest, syncope or convulsions (or both) may result. Unless a clear, reversible cause is found, most symptomatic patients require implantation of a permanent pacemaker.

Arrhythmias are detected either because they produce symptoms or because they are detected during monitoring. Arrhythmias causing sudden death, syncope, or near syncope require further evaluation and treatment unless they are related to conditions that are reversible or immediately treatable (eg, electrolyte abnormalities or acute MI). In contrast, there is controversy over when and how to evaluate and treat rhythm disturbances that are not symptomatic but are possible markers for more serious abnormalities (eg, nonsustained ventricular tachycardia). This uncertainty reflects two issues: (1) the difficulty of reliably stratifying patients into high-risk and low-risk groups, and (2) the lack of treatments that are both effective and safe. Thus, screening patients for these so-called premonitory abnormalities is often not productive.

The diagnosis of an abnormal tachyarrhythmia often can be made via cardiac monitoring, including in-hospital and ambulatory ECG monitoring, event recorders, continuous mobile cardiac telemetry, or implantable loop recorders. Additionally, optic sensors on wearable devices, such as smartwatches, utilize a passive irregular pulse notification algorithm to identify possible arrhythmia, with a positive predictive value for detection of atrial fibrillation of approximately 70%. Devices, such as certain Apple Watches and the AliveCor device, can record actual electrocardiograms of rhythm that can be transmitted to healthcare providers. More invasive testing, including catheter-based electrophysiologic studies (to assess sinus node function, AV conduction, and inducibility of arrhythmias), and tests of autonomic nervous system function (tilt-table testing) can also be performed. These are discussed below and in the subsequent sections on individual rhythm disturbance and symptomatic presentation. In general, these techniques are more successful in diagnosing symptomatic arrhythmias than in predicting ...

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