Heart rhythm problems

 

Heart rhythm problems, known as arrhythmias, are due to abnormalities in the electrical excitement of the heart either causing a heartbeat than can be too slow or too fast. Arrhythmias are common and experienced by more than two million people a year in the UK.

A range of symptoms can be caused by arrhythmias, the commonest being palpitations, dizziness or blackouts (syncope). Most people with an arrhythmia can lead a normal life after it has been correctly diagnosed and treated.

The heart rhythm service at the Royal Devon and Exeter offers an extensive range of services for patients with heart rhythm problems delivered by a team including consultants in electrophysiology, pacing consultants and imaging consultants. The consultants work closely with a team of cardiac physiologists, specialist nurses, catheter lab nurses and ward nurses.

The range of services include consultant- and nurse-led arrhythmia clinics, simple and complex pacemaker implantation, loop recorder implantation, simple and complex ablation including AF ablation.

More on what we do

The most common types of arrhythmia that cause problems and that are treated at the RDE are:

  • Atrial fibrillation (AF) – this is the most common type, where the heart beats irregularly and faster than normal
  • Supraventricular tachycardia (SVT) – sudden episodes of abnormally fast but regular heart beat
  • Heart block – the heart beats more slowly than normal and can cause people to collapse or get dizzy
  • Ectopic beats - extra beats in addition to normal heart beats that can cause feelings of missed or skipped beats. Usually a safe condition.

The symptoms you have depend on what type of arrhythmia you have. The most common symptoms include:

  • Palpitations (a thumping or fluttering sensation in your chest)
  • Dizziness/feeling as if you may ‘black out’
  • Loss of consciousness
  • Breathlessness
  • Chest discomfort
  • Feeling tired

Patients with symptomatic or dangerous heart rhythm problems will be reviewed in clinic. We will look to establish what type of arrhythmia you have and whether there are any underlying issues.

Following a clinic appointment we may be able to offer reassurance or a diagnosis. Often we will arrange tests that monitor the rhythm of the heart or scans that assess heart function.

To monitor the heart rhythm sometimes an electrical recording of your heart rhythm, called an electrocardiogram (ECG), may be all that is needed.  At other times tests monitoring your heart rhythm over a longer period of time may be needed.

Once we know what we're dealing with, we can help treat your condition.

The full range of investigations that we provided for heart rhythm patients include:

  • 12 lead ECG
  • Holter monitor
  • CardioCall
  • Zio monitor
  • Implantable loop recorders
  • Exercise tests
  • Ajmaline tests
  • Signal averaged ECG
  • Echocardiogram and transoesophageal echocardiogram
  • Cardiac MRI or cardiac CT

Treatments

We can treat some forms of arrhythmia with medication that controls the heart rate. Or it might be that you have to undergo a keyhole surgical procedure, called catheter ablation. This is where the diseased tissue in your heart causing the abnormal rhythm is carefully treated under sedation or general anaesthetic. The process usually takes between one and three hours and you'll be carefully monitored afterwards on our cardiology wards.

We also provide a regular DC cardioversion service that is considered for some patients stuck in persistent atrial flutter or atrial fibrillation.

Patients treated with ablation or a cardioversion will be reviewed in clinic after treatment to check on their progress.

Other forms of treatment involve fitting a pacemaker (a small electrical device) into your chest under local anaesthetic to help your heart beat at a normal rate.

Sometimes an implantable cardioverter defibrillator (ICD) might be inserted, which monitors your heartbeat and can shock your heart into a normal rhythm.

More information on the most common treatments we provide can be found below and in the patient leaflets and documents section below.

What is ablation?

Ablation is a procedure that uses energy (usually radiofrequency) to destroy or isolate sources of abnormal electrical impulses that can cause or maintain atrial fibrillation (AF) or other arrhythmias.  It is performed by placing catheters into the heart through a vein usually in the groin or occasionally the arm or neck, guided by x-ray. The term ablation means making small burns in the heart tissue in order to cause a small scar, which can no longer conduct abnormal impulses. Most healthy tissue is unharmed.

Left atrial ablation for AF

Paroxysmal AF often originates from the four pulmonary veins that drain blood from the lungs into the left atrium. With this procedure, catheters are placed in the heart and guided to the left atrium. Ablation is then performed around the pulmonary veins to prevent the abnormal electrical impulses from entering the left atrium and causing AF. The particular pattern of ablation performed varies from specialist to specialist. In patients with persistent AF, additional lines of ablation in the left atrium may be required. This type of ablation procedure is usually reserved for patients who have significant symptoms from their atrial fibrillation and have failed medication.

What is a cardioversion?

This is the delivery of a small direct electrical current (a shock) to the heart in an attempt to interrupt the abnormal activity, this interruption allows the pacemaker of the heart to step in and a normal rhythm to take over. The small electrical shock is delivered by a specialised machine called a defibrillator. Two pads are placed on your chest and the defibrillator which has two paddles on it is placed over these pads and the electric shock is administered. You will be asleep during the procedure and therefore will not feel anything.

What is a pacemaker?

A pacemaker is a battery operated device, inserted into the body just below the collar bone. A wire or ‘electrode’ leads into the heart.

The most common pacemaker is designed to ‘sense’ the speed of your heart beat. If the rate falls below a certain level, the pacemaker ‘senses’ this and sends impulses along the electrode to stimulate or ‘pace’ the heart beat at a faster more appropriate rate until your own heart beat increases again.

There are many different types of pacemakers which are individually selected for your particular needs.

Why do I need a pacemaker?

There are many reasons why people may need a pacemaker. If your pulse falls to a slow rate you could feel dizzy, tired and sleepy. You may even have been experiencing blackouts which can lead to injury. Some people experience a fast erratic heart rate causing ‘palpitations’. You may also feel breathless. It is also possible not to experience any of the above but your doctor may still advise a pacemaker.

What is an ICD?

ICDs are implanted to protect from serious fast heart rhythm disturbances (arrhythmias).

The ICD is a small device containing a battery and computer; it differs from an ordinary pacemaker because it has the ability to deliver large electric shocks and can treat fast rhythm problems. It is usually implanted in the left chest wall under the collarbone and connects to the heart via 1, 2 or 3 leads or wires. Its job is to constantly monitor the heart rate. Should it detect a fast rhythm it can deliver electrical therapy to “reset” the heart back into a normal rhythm.

ICDs are mainly aimed at treating electrical problems in the heart, in general they will not alter other cardiac symptoms; for example chest pain or breathlessness.

Patients who are considered for this type of device have either experienced a serious arrhythmia or are likely to do so. Your nurse or doctor can explain how it applies to you.

Our team

Consultants

  • Dr Matthew Lovell - Ablation, complex pacing, simple pacing
  • Dr Steven Podd - Ablation, complex pacing, S-ICD, simple pacing
  • Dr Philip Spurrell - Complex and simple pacing
  • Dr Martina Muggenthaler - Complex and simple pacing, S-ICD
  • Dr Ben Dyer - Complex and simple pacing
  • Dr Alan Taylor - Simple pacing and ICD
  • Dr John Dean - Simple pacing

Arrhythmia Nurses

  • Lynne Bastable - Lead Arrhythmia Nurse
  • Amanda Pugsley
  • Rui Da Silva Dias

Cardioversion Nurse Team

  • Ken James

Cardiac Physiologists working in Electrophysiology

  • Nicola Wilson (Lead for cardiac physiology)
  • Becky Whiteway
  • Felicity Handel
  • Amy Gill

Cardiac Physiologists working in Cardiac Pacing

  • Heather Herbert (Lead for cardiac pacing physiologist)
  • Nicola Wilson
  • Becky Whiteway
  • Felicity Handel
  • Debbie Hakin
  • Laura McKay
  • Angela Jones
  • Kelly Acland
  • Medi Lisasi
  • Amy Gill

Implantable Loop Recorder Team

  • Lynne Bastable (implanter)
  • Courtney Sowden – advanced associate practitioner
  • Michelle Ley - advanced associate practitioner

Where to find us

RD&E Wonford, Barrack Rd, Exeter EX2 5DW

Wards

The cardiology inpatient wards at the RDE are Avon, Taw and Coronary Care Unit (CCU). They can be found on the first floor of the hospital in area C and D (close to the hospital restaurant Oasis). Patients admitted to hospital are usually placed in CCU or Avon ward.

Patients attending for planned procedures such as ablation, cardioversion or pacemaker implantation should attend Taw ward.

More information on our wards is available here.

Medical Outpatients

Consultant and nurse led clinics at RD&E are held in medical outpatients on the ground floor of the RD&E Hospital Wonford. To get there just turn left at the main entrance of the hospital.

Outpatient clinics in Honiton Hospital are held on the ground floor of Honiton Hospital. To get there report to reception at the main entrance and then take the first left.

Contact us

Ward contacts:

  • CCU - 01392 402837
  • Taw - 01392 402836
  • Avon - 01392 402770

We provide ongoing advice and guidance for our existing patients in the following ways: 

Queries for arrhythmia – including palpitations and ablation:

For medical queries about symptoms of arrhythmia or medications and for issues related to ablation, please call the Arrhythmia Nurses on 01392 403813 (9am to 5pm).

For emergency queries out of hours (after 5pm), please call Taw Ward or CCU (numbers above), 24 hrs.

Queries regarding pacemakers and defibrillators:

You can contact the Cardiac Physiologist on 01392 406087 / 01392 402272 and the Cardiac Physiologist Device Remote Monitoring on 01392 408350 (9am to 5pm).

For emergency queries out of hours (after 5 pm), please call Taw Ward or CCU (number above), 24 hrs.

Queries for symptoms related to pacemaker or ICD shocks

Please contact us on 01392 406087 or 01392 408350 (please leave a message if no answer with your name, date of birth and contact number) if you have been feeling dizzy, light headed or blacked out and/or the area around your device becomes red, sore to touch or inflamed.

If your ICD activates, or you think you may have had an ICD shock but feel well, contact the cardiac physiologists during office hours (01392 406087 or 01392 408350) as you will need to have the device checked – if you have a remote monitor we can review your download

If you have two or more shocks, or feel unwell with a single ICD shock dial 999, if appropriate, or make your way to the Emergency Department who will arrange for a Cardiac Physiologist to check your device.

Queries regarding admissions:

For queries regarding date, times, rescheduling of your admission for an ablation or pacemaker please contact cardiac admissions, call 01392 403713.

Consultants secretaries:

  • Dr Matthew Lovell - 01392 402276
  • Dr Steven Podd - 01392 408515
  • Dr Philip Spurrell - 01392 402278
  • Dr Martina Muggenthaler - 01392 408879
  • Dr Ben Dyer - 01392 408874
  • Dr Alan Taylor - 01392 403929
  • Dr John Dean - 01392 402273

Clinics

Arrhythmia, palpitation and ablation clinics:

We perform specialist arrhythmia clinics face to face and via telephone. Clinics are held most days of the week at the RD&E and once a week on a Tuesday at Honiton Hospital. When attending clinic you will be seen by a consultant, specialist nurse or specialist registrar.  In clinic we see new patients, follow up patients and patients post procedure. Please see further details of addresses and location in the ‘Where to Find Us’ section above.

Pacemaker clinics:

Pacemaker clinics to check pacemakers and defibrillator are run 9am to 5 pm on Monday-Fridays in the department of Cardiology. This clinic is located in area D found on the first floor of the RD&E Hospital opposite the hospital restaurant called Oasis.

Changes in pacemaker clinic in response to COVID-19

For existing device patients:

During COVID-19 we are triaging all our patients around one to two weeks before your appointment is due. We will either call or write to you with our recommendations to your device follow-up care covering your future appointments.

We will either:

  • Defer your appointment
  • Replace your hospital clinic appointment with a remote follow-up if you already have a home monitor
  • If your device is compatible offer you a remote monitor
  • Ask you to come in for a follow-up
  • List you for a generator change without the need to attend another follow-up appointment

For new device patients – all patients

  • Since COVID-19 we routinely provide every patient a remote monitor at implant
  • During COVID-19 the 6 week post implant check will be replaced with a remote monitor check and a phone call to ask how your wound is, if there are any problems we may ask you to take a photo of your wound and email it to us
  • Post COVID-19 we will return to see our patients 6 weeks after their device implant but will utilise their remote monitors more than previously. For some patients we may then only see them in the hospital if a problem arose or their device could not perform all its own self-checks.

We also provide a community arrhythmia clinic at Honiton Hospital on most Tuesdays.

Supporting you

Royal Devon and Exeter AF Patient Days
We usually arrange an atrial fibrillation day twice a year at the RD&E. It is an informal group meeting for AF patients and relatives to provide advice and support. If you would like to attend any future meetings please register your interest by emailing lynne.bastable@nhs.net.

National AF patient day
A national AF patient educational day is usually arranged every year in October. Further details can be found here.

Stress and Anxiety
Suffering with heart rhythm problems often causes stress and anxiety. If you feel you need additional support to help improve you mental and physical wellbeing. Please consider contacting TALKWORKS. This is a free, confidential, NHS talking therapy service for people (aged 18+) in Devon (excluding Plymouth), helping people to feel better and provides tools and techniques to improve mental and physical wellbeing.

Telephone: 0300 555 3344 or click here.

Patient Advice and Liaison Service (PALS)
If you need other help or advice please consider contacting PALS. As a patient, relative or carer you might want to be able to turn to someone here at the RD&E for help, advice or support. This is where our patient advice and liaison service – PALS for short – comes in. Click here to visit the PALS information pages.

Information for healthcare professionals

When to refer to arrhythmia clinic?
Referral to an arrhythmia clinic should be considered for patients with known arrhythmias not responding to treatment, or have on going palpitations interfering with their quality of life or blackouts.

Referral to arrhythmia clinic can also be made for patients with recurrent palpitations or syncope and need investigation to confirm a diagnosis.

If a patient with palpitations or syncope has a close relative who died suddenly and unexpectedly below the age of 35, referral for screening to look for an inherited condition should also be made.

Urgent referral is also recommended in the setting of palpitations or syncope with abnormal ECG, previous history of structural heart disease (e.g., myocardial infarction) or family history of inherited cardiac conditions or sudden cardiac death.

When to refer patients with atrial fibrillation?
Please consider referring patients in the following categories:

  • Treatment with rate control medication has failed to improve symptoms and rhythm control strategy is now being considered.
  • AF is associated with significant underlying heart disease or heart failure.
  • At any stage if current treatment is failing to control symptoms due to AF.
  • Acute onset of AF for less than 48 hrs and rhythm control strategy is preferred (would need acute admission to AMU or refer as below).

If you need advice for an acutely unwell patient with arrhythmia or syncope
Please contact CCU (01392 402837) at the RD&E or bleep the day Cardiology SpR via the RD&E switchboard.

Out of hours please phone CCU for advice, who can liaise with the cardiology consultant on-call if required.

How to refer
All NHS GP referrals may be submitted using the NHS e-Referral Service (e-RS). Referrals can also be sent by post. Please refer to specialty: Cardiology with a clinic type: Arrhythmia

Advice and guidance facility through e-RS is also offered Monday-Friday during normal working hours of 9am to 5pm.

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