Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, Warrick Bishop here. Today what I'd like to share with you is a little bit about ventricular ectopic beats. So these are palpitations that I'm seeing a fair bit of at the moment. And ventricular ectopic beats are characterized by a funny thump or flop or a sensation that the heart's going to jump out of the chest. So I see people. who report these particular palpitations that really give rise to a funny symptom of movement within the chest, a shake or an uncertainty within the chest. So that's the symptom that people turn up with, a palpitation that feels really quite concerning, generally when they're relaxing or something like that. When we investigate these sort of palpitations, I'll often get a halter monitor. to monitor these people's pulse rate. And what I'm trying to try and do is have them wear the HALT monitor when one of these palpitations occurs so that they can press a little button or make a note so that we can match up their symptom with what we see on the electrical trace. So this is what a palpitation looks like. I've got a little trace here. Hopefully you can see it. There's a normal bead, a normal bead, and then clearly something abnormal here. Normal beat, normal beat, normal beat, normal beat, normal beat, something abnormal here. So if the patient indicates that they've got a funny sensation and that lines up with one of these ventricular ectopic beats, which are able to be characterized by the ECG trace, then we've got a diagnosis. And more often than not, I like to get an ultrasound of their heart to make sure that their heart is structurally and functionally normal. Now, if the heart is structurally and functionally normal and this palpitation has occurred, then in general terms, this is a fairly benign situation. It's a different story if people are getting these funny heartbeats and their heart is structurally abnormal. This can be quite a concern and we really do need to know that because it's a very different scenario. But we're going to stick with people who are fit and well with normal hearts, but getting ventricular ectopic beats or palpitations. So if I can make that diagnosis with someone, then it's important to explain to them what's going on. And I do that by trying to explain the ECG and therefore how a ventricular ectopic beat looks on the ECG and how it creates those symptoms. So for those of you who have maybe read my atrial fibrillation explain book or have looked at some of the stuff. on the Healthy Heart Network, you may be quite familiar with the idea that the heart is a simple four-chambered structure. Two chambers on the right side, two chambers on the left side. In the higher part of the top chamber on the right side is the area that beats the drum that the rest of the heart marches to. So the cells in that area... depolarize and that electrical depolarization moves through the top part of the heart, almost like a Mexican wave, which is really cool. So imagine a whole heap of dominoes, that electrical current moves through the top part of the heart like that, like a beautiful Mexican wave. Now, if we were to consider that we had an electrode, Looking at that electrical activity, so I'm going to imagine an electrode is like an eyeball. And the eyeball, if it sees current coming towards it, sees an upward deflection. If the eyeball sees current going away from it, it's a downward deflection. And if the current is neither going away or toward, but going sort of, I guess at 90 degrees, then it doesn't show a deflection at all. So the first depolarization, that electrical activity through the top parts of the heart, give rise to a little bump. And that little bump, we happen to call a P wave. It's just a terminology we use. The electrical activity then goes through from the top two chambers of the heart down into the bottom two chambers of the heart through a special node, which slows conduction momentarily. this remarkable thing happens where the electrical activity going into the bottom chambers of the heart or the ventricles of the heart is distributed by these special cells that act like wires within the heart. And these fantastic little wires distribute the electrical activity to the furthest part of the heart. and the lateral parts of the heart so that the heart contracts from the distal and lateral parts squeezing blood out. If the electrical signal didn't start at those more distal points and started at the proximal points, then the heart would squeeze in on itself and trap blood inside it and that would be bad design. So we've got this remarkable situation where the electrical activity passes through the lower chambers of the heart and the ECG... as seen by the electrode, creates this very nice narrow spike showing that each side of the ventricle, the two extreme sides or the lateral aspects are being activated electrically at about the same time. So a nice narrow synchronized electrical signal. And then there's a nice reorganization of, then there's a nice reorganization of the electrical activity of the cells within the heart and we get a final bump on our ECG trace. So if you are able to see this, for those who were just going to listen, you may not get it so easily, but here is a little bump, a spiky bump and another bump as I've drawn here. a little bump, a spiky bump, and another bump. So normal heartbeat. We'll try one more just down here. Little bump, spiky bump, bigger bump, repolarization. Now, this is a really cool thing to get. If we were able to take a beating heart, this is a bit crazy, but run with it. If we were able to take a beating heart and separate it, immediately to all its single cells, like a magical, almost an Indiana Jones thing, but separate all the cells of a beating heart onto a big table. What we would see is each of those cells individually would contract the cells that came from the top part of the heart where the a pacemaker, if the heart is generated, they would beat the fastest and the cells from the bottom part of the heart would beat the slowest. But these cells, like little wiggly worms, if we could spread them all out on a table, they would all pulsate. And that's because heart cells have a thing called automaticity. And automaticity means that they'll automatically contract to their own devices. And the reason why is because they've got leaky cell membranes. And those leaky cell membranes allow electrolytes to move through the cell until the charge changes over that cell. And when that charge changes, that kicks off the electrical signal that activates contraction. Very, very cool. But what it also means is that every cell in the heart can actually originate a heartbeat of its own. So let's come back to our ventricular ectopic beat story. Imagine now that we've got some cells sitting in one of the ventricles and those cells are a little bit agitated or fired up and they have the opportunity for a bit of automaticity and they clump together and they fire off. And they fire off between normal heartbeats. But when they fire off, this time, the electrical signal spreads like a Mexican wave from the ventricle where it arises to the other side of the heart. And that Mexican wave is not through the normal conduction tissue. So it doesn't move with the same synchronicity. And if we were to try and imagine what that would look like, on an ECG, then what we would see is an unusual, broad pattern representing the depolarization of the bottom part of the heart. Well, this is a ventricular ectopic beat. Ventricular meaning it arises in the ventricle, so the bottom chambers of the heart. Ectopic meaning out of place. And beat meaning it gives rise to a heartbeat. a broad depolarization which doesn't go through the normal uh electrical wires of the heart and it gives rise to something that looks like this on a monitor so very clearly this person has had a ventricular ectopic beat now the consequence of that abnormal depolarization is that the heart doesn't contract synchronously it's going from side to side And you can imagine that's almost like a wobble. So I explain all this to my patients so they know exactly what ventricular ectopic beats are about and why they feel what they feel. So before I put it all together, let's do a little bit more. We're very close. So when we look at ectopic beats, they squeeze in. and they come in a little bit early. So there's a normal space between beats, and then there's a smaller space between beats. So I've written there, normal, normal space, normal space, normal space. When a ventricular topic beat comes in, it comes in early. And because of the electrical disruption of the lower part of the heart, it takes longer for the heart to get reorganized and ready to beat again. So there's a longer pause until the next normal beat. Now the next normal beat, because it's got a longer pause until it fires off, until the heart contracts, during that longer period of time, the blood flow back to the heart continues. And because the blood flow back to the heart continues, at the same rate, then this beak after the ectopic beak with the slightly longer pause has more volume in it and therefore a greater presence or a larger amount of blood is expelled with that contraction. So here we go. So the symptom of ectopic beats is related to this extra beak coming in early, the wobble, the pause, And then the big beat that follows. So people with atopic beats will feel their heart beating normally like this. And then an extra beat will come in. It'll pause, wobble, and then boom. And people think their heart's going to fall out of their chest. I haven't seen it happen in all the years I've been doing cardiology. So there you go. Boom. So this causes a great deal of distress to people because it scares the wits out of them. One of the things that's really noticeable about ectopic beats is they occur when people are relaxing and when they're noticing them. And if you think about it, if the ectopic beat is a little bit like trying to stick a stick between the spokes of a bicycle wheel, trying to get an extra one in, an ectopic beat in, if you spin a bicycle wheel really quickly... then it's hard to get a stick between the spokes. Similarly, if the heart's beating very quickly, if you're exercising and active, then it's very hard to get an extra beating. But if you just got home and you've just relaxed and maybe you've had dinner or maybe a glass of wine and you're sitting on the couch and you're watching the telly and the heart slows down, then boom, an extra beat can creep in. Or you lay in bed and boom, an extra beat creeps in. Well, lo and behold, This is what people describe. So when do people get ventricular ectopic beats? Well, I see them most commonly during exam times or when people are having a stoush with the ATO or if they're having issues at home, maybe like our builder at the very beginning. Stress. Stress is really bad. for ventricular ectopic beats. But the other situation where I see them really commonly is because the heart is so closely approximated to the gut. I see people with reflux and esophageal, distal esophageal or gastric issues, often when their gastric issues are playing up, get ventricular ectopic beats because of the neurological wiring is so close, there must be some crossover that stimulates the heart and causes increased irritability. Well, what can you do about it? Generally, we don't treat it. The story I told you at the very beginning, I gave this gentleman a little bit of beta blocker. We don't normally do that. And I really did it for him to try and just settle things down. In general terms, I say to people, look, the stress is a major play. Try and dampen that down and they will go off their own. They do come and go in people's lives. They're not a bad sign. I'm certainly not a sign of anything. And that's the important reason for getting an ultrasound of the heart, just to make sure that we're dealing with a structurally normal heart. If people do want to take something, I recommend good doses of omega-3 oil. This works really well as a membrane stabiliser. And I reckon 60 or 70% of patients will come back and tell me that the omega-3 oils have helped. Now, I can't be sure, actually. If the omega-3 oil has helped or if the person's situation has just changed and the ventricular ectopic being waxed and waned. The other thing that can help is magnesium. So magnesium and or fish oil or fish oil and or magnesium can all help. A bit of relaxation can help. Getting up and moving around and increasing the heart rate will help as well. That's a bit of a wrap on ventricular ectopic beats and a little bit of mention about stress because there's been a bit of that with COVID-19 lately. I'm going to wish you all the very best. Take care. Please look after your health. If you've got any queries or questions, drop me a note. I'd love to hear what you would like to know about. What you would like to. know about and i'll do my best to answer for you uh this is a journey of looking after your health your heart and please don't die from a heart attack you have been listening to another podcast from dr Warrick visit his website at dr Warrickbishop.com for the latest news on heart disease if you love this podcast feel free to leave us a review
