Extrasystole: symptoms, diagnosis and treatment

An extrasystole is an often benign alteration of the heart rhythm

It is an early pulsating contraction of the heart, which the affected individual may clearly perceive as an abnormal contraction of the organ, an “added beat” or “irregular” compared to the normal heartbeat, but which only instrumental tests are able to detect and accurately typify

What is extrasystole?

An extrasystole is the most common form of cardiac arrhythmia.

Extrasystoles are in fact extremely common, both in completely healthy people and in patients with an underlying heart disease or other pathological conditions.

But in most cases, this is not a worrying or pathological disorder.

Physiologically, the heartbeat originates from the sinoatrial node, which is located in the upper part of the right atrium, one of the four chambers of the heart, and near the superior vena cava.

This is the “electrical control unit” from which the electrical impulse, first passing through the atria and then the ventricles, causes the heart to contract, allowing blood to be pumped around the body (systole is when the heart contracts, while diastole is when it relaxes).

In the case of extrasystole, the contraction stimulus does not come from the sinoatrial node but is located elsewhere (atria, ventricles, AV junction), interfering with the normal conduction of the electrical impulse: the ectopic impulse bursts at any phase of the cardiac cycle and often modifies the duration of ventricular diastole (depending on whether the extrasystole is in an early or late phase of diastole), which may reduce cardiac output, especially if the extrasystoles are frequent or repetitive.

Depending on the origin of the stimulus causing the extrasystolic beat, a distinction is made between an atrial extrasystole, when the stimulus comes from the muscles of the atrium; a ventricular extrasystole, when it comes from the muscles of the ventricle; an atrioventricular or nodal junctional extrasystole, with the stimulus coming from the atrioventricular node.


Extrasystole, the symptoms

Altered pulsations may be extemporaneous (so-called “blanks”) or frequent, with a manifestation that follows a certain regularity or not.

However, the individual with an extrasystole does not always feel these abnormal contractions, as the condition is often asymptomatic.

If they do, they may experience a sort of ‘fluttering’ in the chest at the heart or a sort of ’emptiness’, a stopping of the heartbeat, a thump in the heart.

Most extrasystoles are not felt by the patient, especially if they are isolated and occasional.

Symptomatic patients may instead have the sensation of a “missing heartbeat” or a “more intense heartbeat”, or feel a sort of “flapping”, a “flickering in the middle of the chest” or a sort of “thud” in the chest at the heart, a “hollow”, a “dive” in the heart.

If, on the other hand, the extrasystoles are repetitive (and occur in pairs/triplets, or alternate with the normal rhythm, resulting in a bi/tri/quadrigeminal rhythm) or are frequent and last for longer, the rhythm of the heart changes and is often felt by the patient with episodes of palpitations that have an accelerated or irregular heart rhythm.

In some cases, however, the symptoms become more important, especially when associated with prolonged tachycardia: shortness of breath (dyspnoea), increased fatigability (asthenia) and dizziness may appear.

In the case of benign extrasystole, the symptoms tend to worsen at rest, sometimes especially after meals or at night, and may disappear with exercise; if, however, they increase with physical activity, they are often indicative of a more important pathology and require drug therapy or intervention aimed at treating the underlying disease.

For this reason, a detailed description of the symptoms will be essential during the cardiological examination to define the contours of this arrhythmia.

But in addition to the description of symptoms, instrumental examinations are necessary.


Diagnostic examinations: which examinations can be used to accurately diagnose extrasystole?

Certainly, after a thorough medical examination and an accurate anamnestic collection, the electrocardiogram is the simplest test, but if the extrasystole is sporadic and unpredictable, the extemporaneous electrocardiogram will hardly detect the arrhythmic event or allow a correct diagnosis of its nature and/or extent.

Therefore, the examination most appropriately requested by the cardiologist becomes the dynamic electrocardiogram according to Holter, i.e. the recording of the heartbeat for 24 hours, making it possible to count the number of irregular beats, typify them according to their origin, and assess above all their frequency and repetitiveness compared to normal heartbeats and their occurrence or reduction according to daily activities (work, meals, sport, relaxation, rest) and sleep-wake rhythm.

In the event of further doubts or alterations detected during the examination, a colour Doppler echocardiogram may be requested to better evaluate the cardiac structure and investigate the presence of congenital heart structural pathologies (arrhythmogenic dysplasia of the right ventricle, hypertrophic obstructive cardiomyopathy) or those acquired over the years (of an ischaemic or valvular nature) and the stress test, which allows the electrical activity of the heart to be recorded while the patient walks on the treadmill or does an exercise bike.

If the extrasystole disappears or diminishes during exercise, it is usually not considered serious.

On the other hand, if exercise causes or increases the extrasystolic beats, the heart is likely to be pathologically fatigued and further in-depth or invasive examinations will be necessary (cardiac MRI/CT, coronarography, myocardial scintigraphy, electrophysiological study).


Lifestyle can also play a role

Extrasystole can occur at any age, including children.

But in general, the probability of occurrence increases with age. In a healthy heart, in a young person with no pathologies, extrasystole often correlates with a functional disorder and can be associated with stress (physical and psychological), excessive consumption of smoking, caffeine, alcoholic or carbonated beverages, substances of abuse (cocaine and other drugs) or certain medications (digoxin, aminophylline, tricyclic antidepressants).

Fever, excessive anxiety or excessive sport can also be triggering factors.

At other times, extrasystolic beats may result from a lack of calcium, magnesium and especially potassium in the blood or from an excess of calcium.

Resting, correcting these behaviours or alterations causes the extrasystole to disappear.

Extrasystoles are also very frequent in pregnancy, but are related, as in the case of gastro-oesophageal reflux or an excess of abdominal fat, to vagal or sympathetic reflex stimulation from the abdominal organs.

Such premature systoles should not therefore cause alarm and are not related to heart disease.

In fact, this form of arrhythmia, extrasystole, can also occur as a sign of other conditions or diseases that do not involve the heart, such as thyroid disorders (especially hyperthyroidism, but also hypothyroidism), anaemia, untreated high blood pressure, gastro-oesophageal reflux or other digestive and intestinal disorders such as gallstones, constipation, meteorism.

Finally, there are many cardiac pathologies that are associated with extrasystole, and arrhythmia is often one of the many symptoms accompanying the underlying pathology: heart failure, myocardial infarction or coronary artery disease in general, valvular heart disease, infection or inflammation of the heart (myocarditis, endocarditis, pericarditis), hypertrophic obstructive heart disease, arrhythmogenic right ventricular dysplasia or pathologies of the cardiac conduction system.

Therefore, an appropriate lifestyle, correction of cardiovascular risk factors, annual control of standard blood tests and not too intense sporting activity are the ideal prerequisites for a healthy heart and body.

What is the treatment of extrasystole?

Most patients suffering from extrasystole, but otherwise healthy, will not need any therapy, because these phenomena are benign and related to non-pathological conditions (anxiety, digestive difficulties, stress, sleep deprivation).

Reducing the most frequent triggers (caffeine, nicotine, drinks, medication or excessive sport) can certainly be useful and sometimes essential to reduce the frequency or solve the problem, regardless of the symptoms.

In fact, many patients benefit greatly from lifestyle interventions, such as a healthy, light diet, regular, moderate exercise, and regaining and maintaining a healthy weight.

In some anxious individuals, or when the symptoms become particularly bothersome, it is possible to resort to drugs that can slow the heartbeat: usually drugs called beta-blockers are used, at low doses, or even just anxiolytic drugs, which have proved very effective in reducing symptoms caused by stress and fears.

Relaxation techniques (yoga, pilates, autogenic training) in milder forms or anxiolytic/antidepressant drugs and psychotherapy in more severe forms can also become a solution in reducing the symptoms and frequency of heart rhythm alterations.

When extrasystoles are secondary to non-cardiac diseases, for example hyperthyroidism, anaemia or digestive disorders, therapy is obviously aimed at the underlying disease. In the presence of cardiac pathology, extrasystole can cause even more serious arrhythmias, so it may be necessary to resort to antiarrhythmic drugs, beta blockers or calcium channel blockers in some cases, or amiodarone in more complex cases.

When a satisfactory result cannot be achieved with medication, or the underlying heart disease needs to be treated, more invasive interventions are considered (coronarography, valve replacement, radiofrequency ablation, pacemaker implantation).

In most cases, the occasional extrasystole in non-cardiac patients is not a health problem, but it is essential to check with your doctor that it is benign in order to rule out heart disease or other causes.

Once the diagnosis has been made, and above all once the reduction in arrhythmias under stress has been verified, it has now been demonstrated that regular physical activity has a positive effect on reducing extrasystoles and improving both the physical and psychological condition of non-cardiac individuals suffering from extrasystoles.

On the other hand, the presence of heart disease will limit the intensity of physical activity in relation to the type of underlying disease and its prognosis.

However, even a patient with heart disease is advised to engage in regular, mild physical activity, while respecting his or her overall health, and only in limited, more severe cases is absolute rest recommended, regardless of the presence of extrasystoles.

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