Introduction:

The cardiology department at Sir Ganga Ram Hospital was started in 1977 with basic facilities for monitoring and treatment of patients. Over the years, the department has acquired a sophisticated intensive coronary care unit, non invasive lab for Echo, TMT, Holter Monitoring and tilt table test.

In January 1999, a state of art centre called "Dharma Vira Heart Centre" was added to the hospital. The centre is equipped with:

1. Two operation theatres

2. 17 bed post operative complex

3. A digitised cardiac cath lab

4. 10 bed intensive coronary care unit

5. 30 Inpatients beds

We have state-of-the-art services available at our centre, some of the services available are as following

GENERAL CARDIOLOGY SERVICES

Physicians in the heart and vascular program at SGRH offer care for all heart patients, from the sickest patients who need heart transplants to those at risk for developing heart disease. Our physicians and other health care professionals work closely with patients and their families to coordinate additional services, including arrangements for outpatient and home-based care when necessary.

General cardiology services are available through consultant cardiologists and associates in Cardiology.

Services Provided

General cardiology services at SGRH include preoperative evaluation and treatment and assessment of:

• Cardiac murmurs

• Adult congenital heart disease

• Valvular heart disease

• Rheumatic heart disease

• Hypertension and related problems

• Dyslipidaemia

• Disease of the pericarduim

• Atrial fibrillation

• Supraventricular tachycardia

• Infiltrative disease of the heart

• Noninvasive evaluation of heart disease patients

• Congestive heart failure

• Inflammatory disease of the heart with endocarditis

• Disease of the aorta, including Marfan's syndrome and aortic aneurysm

• Other services include care for pregnant women with heart disease

• Management of patients on anticoagulants

Cardiac Catheterisation Laboratory

More than 3,000 invasive procedures are performed each year in the Cardiac Catheterisation Lab. Cath lab teams include highly skilled and specialised nurses, cardiovascular and cath lab technologists. The experienced team assists the cardiologist in providing services 24 hours a day for scheduled and emergency procedures. The Centre provides state-of-the-art imaging equipment that visualizes and detects coronary artery disease. The images can be stored in the system as a guide for immediate or later treatment of the disease process. State-of-the-art electrophysiology equipment is utilised by the cardiologist and staff to diagnose and treat advanced cardiac dysrhythmias (irregular cardiac rhythms).

Procedures performed in the Cardiac Catheterisation Lab include:

1. Left and right heart catheterisation

2. Percutaneous transluminal coronary angiography

3. Percutaneous transluminal coronary angiograplasty, (Coronary Stent)

4. Angiojet thrombectomy (Clot Removal System)

5. Peripheral arteriograms & interventions

6. Permanent pacemaker implantation

7. catheter ablation permanent pacemaker insertion

8. Implantable cardiac defibrillators

9. Cardiac resynchronisation therapy

10. Balloon Valvotomies - Mitral, Aortic and pulmonary

11. Percutaneous Closure of ASD, VSD and PDA

12. Electrophysiology studies

Angiogram (Coronary and peripheral)

Angiography or angiogram, a study of blood flow in blood vessels, is performed by an interventional radiologist to obtain information about blood vessels. The physician places a catheter (small tube) into a blood vessel and injects dye (contrast) in order to examine the blood vessel under x-ray.

Angiography has been used for 40 years. Complications are infrequent. It is imperative that the physician know if you have a history of allergic reactions, kidney disease, diabetes, multiple myeloma or other blood system problems because the dye can injure the kidneys.

Trans-radial coronary angiography programe at SGRH

The usual approach for coronary angiography is via the femoral artery in the right groin. The patients have to stay in the hospital overnight and keep the right leg immobile for 6-8 hours after the procedure leading to some amount of patient discomfort. In the new technique of trans-radial angiography, the procedure is done though the radial artery in the right wrist. The patient walks out of the cardiac catheterisation lab and can be discharged in a couple of hours.

The advantages of the trans-radial approach are early ambulation, same day discharge and greater patient comfort. Also, the rare complications of the trans-femoral approach like bleeding, requiring blood are completely eliminated.

The patient usually walks into the cath lab for the procedure and half an hour later, walks out of the lab after the test is completed, with just a band on his right wrist. He can immediately have his lunch and can also be discharged from the hospital within 2 hours. Cardiology department of the hospital continues to strive and innovate to provide utmost patient comfort while at the same time providing state-of-the art cutting edge diagnostics and treatment. This 'radial artery angiography programme is one such example.

Catheter Ablation of arrythmias

This is a procedure to treat abnormal fast heart rhythms. In particular, people may be born with abnormal electrical connections that predispose them to a fast rhythm called "supraventricular tachycardia" or SVT for short.

For the most part, SVTs are benign, but they can be a nuisance and even cause fainting syncope. Usually, the cause for an SVT is an abnormal connection or tract between the upper and lower chambers (ventricle), due to which it fires rapidly independently of everything else.

When patients experience an episode of SVT they usually notice a sudden onset of lightheadedness or shortness of breath. They may or may not be aware that their heart is beating as fast as 200 times a minute!

In some individuals SVT is a rare occurrence, and they can be treated with medication. In other individuals SVT can be frequent and quite distressing requiring visits to the emergency room for treatment. In these situations, catheter ablation is recommended to isolate the precise area of the heart that is responsible for the rapid heartbeat, and cauterise that area with radiofrequency energy to permanently cure the disorder.

Implantable Cardioverter Defibrillator (ICD)

The primary function of an ICD is to recognise and treat dangerous fast heart rhythms from the lower chambers of the heart (ventricles) such as ventricular tachycardia and ventricular fibrillation.

First introduced in the early 1990s, these devices have undergone a tremendous evolution, with an ever-decreasing size yet with increasing power and complexity. Similar to a pacemaker (indeed each ICD also incorporates a fully functional pacemaker), these devices consists of a generator (a battery and electronic circuits) and one or more electrode leads, threaded through a vein under the collarbone to the inside of the heart chambers.

Several important differences need to be mentioned: compared to a pacemaker generator, the ICD generator is significantly larger (about the size of a small pager) and unlike a pacemaker, the ICD can recognise and effectively treat fast heart rhythm problems.

The ICD is very effective in terminating fast abnormal heart rhythms, either by shock (defibrillation/cardioversion) or by means of overdrive pacing.

Several large clinical studies have recently shown that, when added to optimal medical therapy, the ICD can reduce the death rate in patients with severe heart disease by 30-45%. Individuals with an ICD should receive regular follow up to assure proper function of the device and assess the battery status.

CARDIAC RESYNCHRONISATION THERAPY

What is cardiac resynchronisation therapy?  

Cardiac resynchronisation therapy (CRT) is used to to treat the delay in heart ventricle contractions that occur in some people with advanced heart failure The CRT pacing device (also called a biventricular pacemaker) is an electronic,     battery-powered device that is surgically implanted under the skin.

The device has 2 or 3 leads (wires) that are  positioned in the heart to help the heart beat in a more  balanced way. The leads are implanted through a vein in the  right atrium and right  ventricle and into the coronary sinus vein to pace the left ventricle.

How it works: When your heart rate drops below the set rate (programmed by your doctor), the device generates (fires) small electrical impulses that pass through the leads to the heart muscle. These impulses make the lower  chambers (ventricles) of the heart muscle contract, causing the right and left ventricles to pump together. The end  result is improved cardiac function.

CRT Device

The CRT device (biventricular pacemaker)  has 2 or 3 leads that are positioned in the:

1. Right atrium

2. Right ventricle

3. Left ventricle (via the coronary sinus vein)

Electrical system of the heart

The atria and ventricles work together, alternately contracting and relaxing to pump blood through the  heart. The electrical system of the heart is the power source that makes this possible.

Normally, the electrical impulse begins at the sinoatrial (SA) node, located in the right atrium. The electrical activity spreads through the walls of the atria, causing them to contract.

Next, the electrical impulse travels through the AV node, located between the atria and ventricles. The  AV node acts like a gate that slows the electrical signal before it enters the ventricles. This delay gives the atria time to contract before the ventricles do. From the AV node, the electrical impulse travels  through the His-Purkinje network, a pathway of specialised electricity-conducting fibres. Then the  impulse travels into the muscular walls of the ventricles, causing them to contract. This sequence occurs with every heartbeat (usually 60-100 times per minute).

CRT and ICD therapy

Some patients with heart failure may benefit from a combination of CRT and an implantable cardiac defibrillator (ICD). These  devices combine biventricular pacing with anti-tachycardia pacing and internal defibrillators to deliver treatment as needed.

Benefits of CRT

CRT improves symptoms of heart failure in about 50 percent of patients who have been treated maximally with medications but  still have severe or moderately severe heart failure symptoms. CRT improves survival, quality of life, heart function, the ability to  exercise, and helps decrease hospitalisations in select patients with severe or moderately severe heart failure.

Who is eligible to receive a CRT device? 

People with heart failure who have a poor ejection fraction (<35%) are at risk for fast, irregular and sometimes life-threatening heart rhythms. Ejection fraction is the measurement of how much blood is being pumped out of the left  ventricle of the heart. CRT may be appropriate for people who:

• Have severe or moderately severe heart failure symptoms

• Are taking medications to treat heart failure

• Have delayed electrical activation of the heart (such as intraventricular conduction delay or bundle branch block)

• Have a history of cardiac arrest or are at risk for cardiac arrest

Pacemaker

The primary function of a pacemaker is to treat or prevent slow heart rates. Slow heart rates may occur as a result of aging or diseases that affect the heart's own electrical system or may be due to medications necessary to treat various heart conditions.

Introduced in the mid 1950s, these devices are typically implanted through a small incision under the skin in the region of the left or right collarbone.

A pacemaker consists of a generator (a battery with electronic circuits) and one or more electrode leads, threaded through a vein under the collarbone to the inside of the heart chambers. The pacemaker battery may last up to 7-10 years and individuals with a pacemaker should receive regular follow up to assure proper function of the device and the battery.

Modern pacemakers fit comfortably into typical everyday life, and do not interfere with any of the usual everyday appliances, such as microwaves.

Electrophysiology (EP)

This is a specialty field within cardiology that studies the mechanism(s) and treatment of heart rhythm problems (arrhythmias). We have electrophysiology facilities for the diagnosis and therapy of arrhythmias and heart blocks. In general, treatment options for heart rhythm disorders may consist of medication, catheter abalation, placement of a pacemaker or implantable defibrillator.

PRIMARY ANGIOPLASTY PROGRAME

Primary angioplasty at the Dharma Vira Heart Centre: SGRH experience

Primary angioplasty with stent implantation is now widely recognised as the treatment of choice for acute myocardial infarction. Numerous studies have documented the superiority of this mode of treatment over the traditional thrombolytic therapy.

The Dharma Vira Heart Centre has an active primary angioplasty programme with an interventional cardiologist and other necessary staff such as an anaesthetist, a technician, staff nurse, etc. available round-the-clock.

Recently, the centre achieved a unique milestone-500 primary angioplasties had been performed since 2001. Primary angioplasties comprise approximately one-fourth of the total number of angioplasties done at the Centre.

Non Invasive Cardiology Services

A full-fledged non invasive cardiac lab with three latest generation echo machines for adult, paediatric, fetal, trans poesophageal and peripheral echocardiographic imaging is available.

Stress echo, Electrocardiography, 24 hours holter monitoring, Head up Tilt testing, treadmill test are done routinely to aid in cardiac diagnostic yield. Stress Thallium for non invasive assessment of coronary artery disease are also available.

CT angiography the latest technique for non-invasive diagnosis of heart disease is also now available in the hospital.

The diagnostic cardiology team performs a variety of testing procedures, which are interpreted and correlated with clinical data to arrive at the diagnosis. Some tests are also performed in the Nuclear Medicine Department.

Some of the common diagnostic procedures performed are

• Echocardiography:

• Electrocradiogram (ECG)

• Stress Echocardiography

• Head Up Tilt Test

• Tread Mill Test

• Holter monitoring

• Fetal Echocardiography

• Trans Oesophageal Echocardiography(

CT Angiography

CT angiography is an examination that uses x-rays to visualise blood flow in arterial and venous vessels throughout the body, from arteries serving the brain to those bringing blood to the lungs, kidneys, and arms and legs. CT combines the use of x-rays with computerised analysis of the images. Beams of x-rays are passed from a rotating device through the area of interest in the patient's body from several different angles to create cross-sectional images, which then are assembled by computer into a three-dimensional picture of the area being studied. Compared to conventional angiography, which involves placing a sizable catheter and injecting contrast material into a large artery or vein, CTA is a much less invasive and more patient-friendly procedure-contrast material is injected into a small peripheral vein by using a small needle or catheter. This type of examination has been used to screen large numbers of individuals for arterial disease.

Some common uses of the procedure other than Coronary angiography

• Examine the pulmonary arteries in the lungs to rule out pulmonary embolism, a serious but treatable condition.

• Visualise blood flow in the renal arteries (those supplying the kidneys) in patients with high blood pressure and those suspected of having kidney disorders. Also done in prospective kidney donors.

• Identify aneurysms in the aorta or in other major blood vessels. Aneurysms are diseased areas of a weakened blood vessel wall that bulges out-like a bulge in a tyre. Aneurysms are life-threatening because they can rupture.

• Identify dissection in the aorta or its major branches. Dissection means that the layers of the artery wall peel away from each other-like the layers of an onion. Dissection can cause pain and can be life-threatening.

• Identify a small aneurysm or arteriovenous malformation inside the brain that can be life-threatening.

• Detect atherosclerosis that has narrowed the arteries to the legs.

• Detect thrombosis (clots) in veins, for example large veins in the pelvis and legs. Such clots can travel to the lungs and result in pulmonary embolism.

Benefits

• CTA can be used to examine blood vessels in many key areas of the body, including the brain, kidneys, pelvis, and the lungs. This method displays the anatomical detail of blood vessels more precisely than magnetic resonance imaging (MRI) or ultrasound.

• CTA is a useful way of screening for arterial disease because it is safer and much less time-consuming than the conventional angiography and is a cost-effective procedure. There is also less discomfort because contrast material is injected into an arm vein rather than into a large artery in the groin.

Risks

• There is a risk of an allergic reaction-which may be serious-whenever contrast material containing iodine is injected. CTA should be avoided in patients with kidney disease or severe diabetes, because x-ray contrast material can further harm kidney function.

• Women should always inform their doctor or x-ray technologist if there is any possibility that they are pregnant.

Cardiac Nuclear Exercise

Cardiac nuclear exercise tests are done to document blockages in the arteries.

First an image is taken (myocardial perfusion scan) to assess blood flow to the heart muscle.Here a radioactive substance called a tracer (thallium or technetium) is injected into an arm vein. The radioactive tracer temporarily marks the red blood cells to allow the doctor to document blood flow to the heart muscle.

Once the tracer has been injected into the bloodstream, a special camera views the amount of the tracer that reaches the heart muscle (this procedure is called scintigraphy).

Another set of computerised camera images are taken in Nuclear Medicine to determine the blood flow to the heart muscle following both the exercise treadmill and the dilating agent tests. These images reflect the blood flow at peak exercise or the maximum capacity of the vessels. The colour intensity changes on the computer images, which helps determine the activity in the blood flow to the heart muscle.

Other names for these types of cardiac nuclear tests may be:

• Nuclear Stress Test

• MIBI stress tests

• Myocardial perfusion scintigraphy

• Thallium myocardial imaging

• Thallium stress scintigram / test

Preventive cardiology services

Prevention of heart diseases and rehabilitation of such patients as well as a hyperlipidaemia prevention clinic with the aim to counsel patients on the preventive aspects of heart disease in also available. They are educated about the need to keep the various types of cholesterol within normal levels.

Yoga Lifestyle Clinic

Yoga is an alternative system of healing, its power being widely harnessed to prevent and treat various diseases of the heart. Yoga is undoubtedly a reliable avenue for holistic health. Disease is a manifestation of underlying disharmony in the mind-body domain.

Yogic way of life offers a solution to elevate the health of body, mind and soul.
Yoga has an important role in the prevention of cardiovascular diseases that includes recurrence of heart attacks, hypertension and coronary heart diseases. Yoga influences the hypothalamus directly the area of the brain, that controls the endocrine activity and helps coronary artery disease. 
A complete yoga program involves exercises (asanas), breath control (pranayama), sleep control (yoga Nidra) and mind control (meditation), which are the tenets for cardiac health; also the reason why cardiologists universally recommend yoga to the patients. The curative benefits of yoga enhance heart health, lowers blood pressure, reduce chronic stress, boost the immune system and enhance cognitive ability.

Facilities available at Yoga Lifestyle Clinic at Sir Ganga Ram Hospital

Yoga is being taught by an expert Yoga Instructor under supervision of Prof. S.C. Manchanda, Senior Consultant Cardiologist. Yoga Lifestyle is being used for reversing heart diseases by a scientific approach.

• For rehabilitation and prevention of coronary heart disease after angioplasty, bypass surgery and heart attacks.

• For control of hypertension, diabetes mellitus, obesity, dyslipidaemia, bronchial asthma, migraine, joint pains, irritable bowel syndrome, depression and anxiety.

• For stress management of executives, professionals, etc.

• In addition, advice is given regarding healthy diet, physical exercise and tobacco cessation for leading a healthy life.

HEALTH CHECK PROGRAMME

FOR GOOD HEALTH AND HAPPY LIVING

Sir Ganga Ram Hospital is pleased to offer comprehensive Health Check-up Schemes. Objective of this program is promotion of health and prevention of diseases. In addition to routine medical check-up which is recommended for people of all age group, we offer Executive Health Check-up for all office executives who work under rigid schedule with odd working hours. The purpose of executive health check-up is to examine tha apparently normal people, involved and ofter busy in their responsible jobs, so as to pick up any abnormality at its incubation stage and thus take remedial measures.

PAEDIATRIC CARDIOLOGY

Paediatric Cardiology Services at Ganga Ram Hospital is one of the few units in the country providing Cardiac Services dedicated to children.

Diagnosis of congenital heart disease is provided by the use of Electrocardiogram, Echocardiogram and family is counseled regarding further management. Rarely a cardiac catheterisation needs to be done for a complete diagnosis.

Fetal Cardiology

Fetal cardiology is a branch of paediatric cardiology specialising in the diagnosis and management of heart problems in the fetus (baby while it is in the mother's womb). Fetal heart problems include

1. Congenital defects - heart defects that occur due to genetic causes or abnormal development due to maternal drug, medicine or environment exposures

2. Acquired defects - defects or abnormalities that occur in the babies after the heart has been formed (for instance, a thickened heart in a baby heart mother has diabetes)

3. Rhythm abnormalities - these can occur because of heart defects, maternal drug or medicine exposures, or due to abnormalities in the electrical system of the heart

Emergency services

The hospital is geared up to take care of all cardiac emergencies. Ambulance services are available to transport very sick patients. We have facilities to transport the sick patients including those requiring ventilatory support, pacing and intra-aortic balloon pump to our centre.

We are able to transport the patients from any corner of Delhi and the peripheries. All one needs to do is to get in touch with us on our helpline numbers

Contact Help line Numbers

- 09312943730, 01142251592, 01142251593 , 01142251037

Contact Email: dharmaviraheartcentre@india.com

Appointments are available during normal business hours, monday through saturday. To schedule a visit with a heart specialist, call (011)42251534, (011)42251037

Community Services

Community Services are done by free heart check up camps held every 2 months, both within and outside the city. Patients are examined by consultants and free ECG, blood sugar and echo are done.

Heart point programme is conducted to update physicians in management of cardiovascular disease. This is a unique programme, as it involves keeping the general physicians informed about the latest in cardiac diseases. This is done by regular interaction every two months. One such meeting was held in Colombo from 24 to 27 January 2004.

Academics: The centre is recognised for DNB course in cardiology. Candidates are selected on the basis of an examination. Regular bedside teaching, weekly journals and seminar presentation are conducted. They are posted to the echo lab, cath lab, coronary care unit and wards on a rotation basis. We are a part of many ongoing international trials both in clinical pharmacology and interventional cardiology.

COMMON CARDIAC CONDITIONS

What Happens During a Heart Attack?

A heart attack (myocardial infarction or MI) occurs when a heart muscle has reduced blood flow. Sometimes plaque inside heart arteries breaks open or ruptures; a clot then can form that blocks blood flow through the artery.

Plaque is made up of cholesterol, white blood cells, calcium, and other components and is surrounded by a thin layer of cells. Different things-one of which may be high blood pressure-can cause the capillary to tear or rupture. Cholesterol then leaks out the tear and mixes with blood in the artery and a clot is formed. This blood clot in an artery can sometimes obstruct blood flow to the heart muscle, which causes the heart attack.

Some heart attack symptoms may include:

• Chest pain that is crushing, squeezing, or feels like a heavy weight on the chest.

• Chest pain with sweating, shortness of breath, nausea or vomiting.

• Chest pain that spreads to the neck, jaw, shoulder(s) or arm(s).

• Dizziness or lightheadedness.

• Fast or irregular heartbeat.

• Sometimes symptoms are only arm or back pain (not only chest pain).

Often pain with MI will wax or wan and may improve with rest or may happen at rest. It is important to seek emergency care to prevent death. SGRH cardiologists may perform an urgent angioplasty with stent placement to open the artery and return blood flow to the heart.

See the various diagnostic tests that assess your cardiac damage. Depending on these test results, doctors may begin treatment to reduce heart muscle damage caused by a heart attack.

Sudden (Cardiac) Death

This describes a condition in which an individual collapses abruptly and unexpectedly and - unlike syncope - does not recover spontaneously. In the US, approximately 400,000 people die each year due to sudden cardiac death - more deaths than those combined from lung and breast cancer and AIDS.

There are many conditions that can cause sudden death such as bleeding from a tear in the aorta (the largest artery in the body) or in the brain. However, 90% of sudden (cardiac) death episodes are due to an abnormal heart rhythm called ventricular fibrillation (VF). In VF the heart rate in the lower chambers (ventricles) abruptly increases to > 250 beats per minute. Indeed the heart rhythm is extremely chaotic, the heart pump function thus ceases, the blood pressure drops and the patient collapses.

Unless prompt resuscitation with cardiac defibrillation (a shock) is delivered, death occurs within minutes. Many victims of sudden cardiac death have known heart disease (i.e., prior heart attack or myocardial infarction, or congestive heart failure) or are at high risk for heart disease.

Sudden cardiac death is not the same as a heart attack. In a heart attack, one of the coronary arteries blocks up and interrupts the blood flow to a specific region of the heart. In sudden cardiac death, the heart rhythm abruptly becomes chaotic with ventricular fibrillation.

Patients with known severe heart disease are at increased risk for sudden cardiac death and should be evaluated for possible therapy with an implantable cardioverter defibrillator (ICD).

Atrial Fibrillation

This is a heart rhythm disorder that is so common in our population that it deserves a special mention. This is a disorder that principally affects people over the age of 60. The upper chambers of the heart (atria) develop an electrically chaotic rhythm such that these chambers can no longer mechanically pump blood. These chaotic electrical signals cross (conduct) to the lower chambers (ventricles) in a random, irregular fashion, giving the sensation of irregular palpitations. In addition to feeling irregular, the pulse will usually be quite fast, about 100 to 150 beats/minute. Episodes of atrial fibrillation may start and stop of themselves after a few hours. However, over time, the episodes usually last longer until eventually they do not stop by themselves.

Treatment

The treatment of atrial fibrillation is targeted towards controlling the fast pulse and trying to restore a normal (sinus) rhythm. Usually medications are sufficient to control the fast pulse or to try to prevent the heart from going into atrial fibrillation in the first place.

To restore a normal rhythm, the cardiologist may want to do a cardioversion, where the patient is deeply sedated and then a shock is delivered to the heart to reset the normal rhythm.

Sometimes catheter ablation can be helpful-either to help control the heart rate in atrial fibrillation in conjunction with a pacemaker, or in selected younger individuals to treat abnormal electrical connections that can trigger atrial fibrillation.

Preventing Strokes

However, the most important thing of all is to prevent a stroke. Since in atrial fibrillation the upper chambers cannot pump any blood, blood can stagnate in these chambers and form clots. If a clot goes to the brain, there can be a stroke. Therefore, many patients are advised to be on blood thinner called warfarin, (also called coumadin).

Syncope

This is the medical term for "passing out" or "fainting." During syncope, a temporary loss of consciousness together with loss of muscle tone (slumping over or falling) occurs, however the patient recovers quickly and spontaneously. Syncope is due to a transient decrease in blood flow to the brain.

There are many conditions that can cause syncope-some of which may be related to heart disease such as certain heart valve disorders or arrhythmia. The most common condition-the "common faint"-is due to a transient blood pressure and/or heart rate decrease and is typically seen in healthy individuals (for example during blood draws or painful events).

All patients with syncope should be thoroughly evaluated especially if they have known heart disease, as some causes for syncope can potentially be dangerous

Arrhythmias

This is the medical term for "abnormal heart rate and/or rhythm." The heart rhythm may be too slow (bradycardia) or too fast (tachycardia).

The abnormal heart rhythm may originate from the:

• upper chambers (supraventricular tachycardia, atrial fibrillation, atrial flutter) or

• lower chambers (ventricular tachycardia, ventricular fibrillation).

The episodes of arrhythmia may be very brief (non-sustained) or long lasting (sustained). Factors that can cause arrhythmias are stress, caffeine, alcohol, and many forms of heart disease