Arrhythmia

Overview

Arrhythmia is defined as an abnormal disturbance of heart rhythm.

If a patient is acutely unwell or compromised by their arrhythmia then arrange immediate assessment in ED (see red flags below).

If a patient is stable and presents with symptoms of signs of arrhythmia then it is important to undertake an ECG to try to identify a cause.

If the symptoms are intermittent then it is important to try to capture an ECG during an episode either by asking the patient to present immediately to ED or primary care so that this can be undertaken. Alternatively recording devices can be fitted to try to capture an event when it happens.

Many practices now also have been provided wth KardiaMobile hand held devices that can record a single lead rhythm strip.

The Arrhythmia Alliance - UK has useful information for patients and professionals about various conditions, investigations and treatments for arrythmia.

Who to refer

Patients who may not need referral:

• Atrial or ventricular extrasystoles (ectopics)  — if there are no features of underlying heart disease and palpitations are infrequent, reassure the person that the palpitations are unlikely to be a cause for concern.
• Sinus tachycardia — manage the underlying cause where possible - see Palpitations | Health topics A to Z | CKS | NICE.

Patients who may need referral:

Referral route depends on symptoms and pre-existing diagnosis:

Atrial Fibrillation - not all patients with AF will need referral - see Atrial Fibrillation page for further details.

Palpitations without a known diagnosis and a normal ECG - where arrhythmia is suspected then consider the following options: 

• Cardiac monitoring -direct referral available to BHI or NBT via Triage Service (including referral form - embedded in EMIS) if appropriate.
• Electrophysiology (EP) clinic at UHBW or Palpitations Clinic at NBT - consider if preliminary investigations can be done in primary care (i.e. Holter Monitor or Echocardiogram).

Pregnant women without existing cardiac condition or diagnosis and normal resting ECG –where palpitations are suspected to be arrhythmic in origin refer via eRS to Electrophysiology clinic (BHI) to be seen by Arrhythmia Nurse Team or Palpitations Clinic at NBT.

Palpitations with known significant structural heart disease - options include: cardiology valve clinic (BHI) or general cardiology (NBT) unless mild valve disease.

SVT - see red flags below. If admission not required then options include Electrophysiology clinic (BHI) or Palpitations clinic (NBT).

Arrhythmia with a confirmed diagnosis - options include Electrophysiology clinic (BHI) or Palpitations clinic (NBT).

Syncope or pre-syncope with suspected cardiac cause- . See Syncope and TLOC page- options include Cardiac Black Out Clinic (BHI) or General Cardiology Clinic (NBT)

Previous cardiac ablation (within the last 12 months) - refer back to hospital where procedure performed (named consultant if possible).

Known adult congenital heart disease - options include Adult Congenital Heart Disease clinic (BHI) or General Cardiology (NBT).

Family history of sudden cardiac death - see the inherited heart conditions page. If patient is asymptomatic refer to Inherited Cardiac Conditions clinic (BHI) or General Cardiology (NBT)

Children - if aged under 16 then refer to paediatric cardiology via eRS. Adult referrals should be made for patients aged 16 year and over.

If you need advice, or are not sure if referral is needed then consider using Cardiology Advice and Guidance

Red Flags

Refer immediately to emergency department if current palpitations and any of the following (1):

• Ventricular tachycardia
• Persistent supraventricular tachycardia (SVT). Before deciding to admit, if trained and competent to do so, attempt to terminate the SVT if appropriate by:
  • Valsalva manoeuvre — for example the person blows into a syringe whilst lying down (face up) for 15 seconds.
  • Carotid sinus massage — ensure that a defibrillator is available, as very rarely terminating an SVT can provoke other arrhythmias. Ideally, record an electrocardiogram (ECG) continuously during and after the procedure.
• Haemodynamic instability (hypotension and/or tachycardia).
• High risk structural heart disease including ischemic heart disease.
• Features suggestive of a serious underlying cardiac cause or complication:
  • High degree atrioventricular block on ECG.
  • Significant breathlessness.
  • Chest pain.
  • Syncope or near syncope.
  • Family history of sudden cardiac death under the age of 40 years.
  • Onset of palpitations precipitated by exercise.
• Consider admission for a person with current palpitations and evidence of a serious or life-threatening systemic cause, such as thyrotoxicosis, severe anaemia, or sepsis.

Taken from  Clinical Knowledge Summary - Palpitations

What to do before referral

Investigations

The cardiologists request that clinicians include as much information as possible on their referrals to electrophysiology services and consider whether they are able to arrange preliminary tests as follows:

• ECG - essential before any referral (unless needing ED assessment/admission)
• Bloods - U+Es, FBC, HbA1c, TFTs, cholesterol and LFTs 
• Echocardiogram - not mandatory but consider requesting if structural heart disease is suspected.
• Cardiac Monitoring (Rhythm analysis) - direct referral available via eRS (Triage service) at BHI and NBT.

Managing risk factors

Carry out a cardiovascular risk assessment and manage risk factors as appropriate. See the CKS topic on CVD risk assessment and management for further information.

Give lifestyle advice on reducing or avoiding stress, caffeine, alcohol, smoking, and drugs that can precipitate or exacerbate palpitations.

Services

Bristol Heart Institute

The BHI offers several services that may be appropriate for referral of patients with arrhythmia. They include:

• Cardiac monitoring clinic  Triage service via eRS
• Electrophysiology and complex arrhythmia clinic

NBT

NBT has a comprehensive cardiac service and will accept referrals to the following:

• Cardiac rhythm analysis via Cardiology monitoring Triage service in eRS
• General cardiology clinic via eRS
• Palpitations Clinic - this clinic is closed from 9th March 2024. Patients should be referred for cardiac rhythm analysis or to general cardiology clinic as appropriate

Weston

Weston is now part of UHBW but also has cardiology clinics including:

• General cardiology

Deactivating ICD

If an ICD (Implantable Cardioverter Defibrillator), CRT-D (Cardiac Resynchronisation Therapy- with Defibrillator), S-ICD (Subcutaneous Implantable Cardioverter Defibrillator) or EV-ICD (Extra Vascular Implantable Cardioverter Defibrillator) has been fitted this may sometimes need to be deactivated in patients who are palliative and/or no longer wish the device to activate

This can usually be coordinated by the hospital where the device was fitted who should be contacted directly (not referred via eRS due to potential delays that this may cause).

The standard operating procedure for UHBW and patients under their care is below:

BHI - For patients under the care of UHBW please refer to the SOP and contact the relevant team. 

Non-Urgent Queries: 

Arrhythmia Nurse Team:  ep.iccnurseadults@uhbw.nhs.uk or 0117 342 6635 

Cardiac Device Physiologists: 0117 342 6561 

Urgent Queries: 

Arrhythmia Nurse Team:  Bleep 6004/6008 via hospital switchboard (only available in hours).

Cardiac Device Physiologists: Bleep 6561 via hospital switchboard

For patients under the care of NBT contact:

Pacemakerclinic@nbt.nhs.uk and also Pacemakeradmin@nht.nhs.uk

Further advice about ICDs can be found below:

Resources for Patients, Relatives and Non-Clinical Persons:

• Deactivation of implantable cardioverter-defibrillators (ICD) towards the end of life: A Guide for Patients and Carers - CIEDs leaflet_patients.pdf (resus.org.uk)
• Arrhythmia Alliance -Home - Arrhythmia Alliance - UK
• British Heart Foundation http://www.bhf.org.uk
• St Peters Hospice - St Peter's Hospice (stpetershospice.org)

Resources and guidance for Health Care Professionals:

• Deactivation of implantable cardioverter-defibrillators towards the end of life: A guide for healthcare professionals from the Resuscitation Council UK the British Cardiovascular Society and the National Council for Palliative Care CIEDs CIEDs Deactivation.pdf (resus.org.uk)
• BHRS (2024) Discontinuation of ICD Shock Therapies towards the End of Life: A Practical Guide. (Includes application of deactivation magnets in emergency) Microsoft Word - BHRS-Discontinuation of ICD shock therapies towards the end of life (JANUARY 2024).docx
• BHRS (2024) Standards for Implantation and Follow-Up of Cardiac Rhythm Management Devices. Microsoft Word - BHRS-standards-January-2024-Implantation-and-Follow-Up-of-CRM-Devices-in-Adults.docx

Resources

(1) Palpitations | Health topics A to Z | CKS | NICE

Patient Information and resources

• Heart palpitations - NHS (www.nhs.uk)
• Arrhythmia - NHS (www.nhs.uk)
• Supraventricular tachycardia (SVT) - NHS (www.nhs.uk)
• Heart block - NHS (www.nhs.uk)
• Bradycardia (Causes, Symptoms, and Treatment) | Patient
• Arrhythmias - Abnormal heart rhythms - BHF
• Home - Arrhythmia Alliance - UK (heartrhythmalliance.org)

Fitness to Drive

• Cardiovascular disorders: assessing fitness to drive - GOV.UK (www.gov.uk)
• Arrhythmia and driving - GOV.UK (www.gov.uk)

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