Restore Your Heart's Natural Rhythm

Understanding Heart Rhythm Problems in the Indian Context

Arrhythmias—abnormal heart rhythms—range from benign (harmless palpitations) to life-threatening (sudden cardiac death). At Ajuda Hospitals, our electrophysiology (EP) team combines advanced diagnostics (Holter, EP studies, 3D mapping), minimally invasive catheter ablation, device therapy (pacemakers, ICDs), and anticoagulation management to restore normal rhythm and prevent stroke.

Atrial fibrillation (AF), the most common sustained arrhythmia, affects 5-7% of Indians over 60—causing palpitations, breathlessness, and a 5x increased stroke risk. Other common arrhythmias include supraventricular tachycardia (SVT)—sudden racing heart curable with ablation—and ventricular arrhythmias causing sudden death in high-risk patients. Our protocols follow ESC Arrhythmia Guidelines, AHA/ACC/HRS Guidelines, and Indian Heart Rhythm Society recommendations.

Whether you're living with atrial fib, experiencing recurrent palpitations, or need pacemaker follow-up, Ajuda's comprehensive arrhythmia program offers cutting-edge therapies and compassionate care.

When to Consult Our Arrhythmia Specialists

Schedule routine evaluation for intermittent palpitations, known atrial fib needing optimization, or pacemaker/ICD follow-up.

Our Diagnostic Approach

Initial Assessment: ECG & Clinical History

12-lead ECG performed immediately—captures rhythm during that moment. If normal but symptoms intermittent, extended monitoring needed.

Symptom Diary:

• Frequency: Daily? Weekly? Monthly?
• Duration: Seconds? Minutes? Hours?
• Triggers: Caffeine, alcohol, exercise, stress, sleep deprivation?
• Associated symptoms: Chest pain, breathlessness, dizziness, syncope?

Risk stratification: Family history of sudden death? Structural heart disease? Prior MI?

Extended Ambulatory Monitoring

Holter Monitor (24-48 hours):

• Wearable device records every heartbeat
• Patient presses button when symptoms occur—correlates rhythm with symptoms
• Quantifies arrhythmia burden (% time in AF, number of PVCs per hour)

Event Recorder (7-30 days):

• For rare palpitations occurring weekly/monthly
• Patient activates when symptoms start—device saves 30-second strips
• Alternatively, smartphone-based ECG apps (AliveCor, Apple Watch) capture single-lead tracings

Implantable Loop Recorder (ILR):

• For cryptogenic syncope (fainting without diagnosis after extensive workup)
• Subcutaneous device inserted under local anesthesia—monitors up to 3 years
• Auto-detects pauses, bradycardia, tachycardia; patient can manually activate

Structural Heart & Metabolic Workup

Echocardiography:

• Rules out valve disease, cardiomyopathy, congenital defects
• Enlarged atria (common in chronic AF)—predicts ablation success
• Low ejection fraction—may indicate need for ICD

Laboratory Tests:

• Thyroid function (TSH, Free T4): Hyperthyroidism causes AF in 10-15% of cases
• Electrolytes (potassium, magnesium): Low levels trigger arrhythmias
• Renal function: Guides medication dosing, anticoagulant choice

Exercise Stress Test:

• Evaluates arrhythmias during/after exercise
• Detects inappropriate sinus tachycardia, catecholamine-sensitive VT

Electrophysiology Study (EP Study)

Invasive diagnostic procedure for:

• Unexplained syncope with high-risk features
• SVT needing ablation—maps exact pathway
• Risk stratification for inherited arrhythmia syndromes (Brugada, long QT)

Process:

• Catheters inserted via femoral vein (groin) reach heart
• Electrical signals recorded from multiple sites
• Arrhythmia induced with programmed stimulation
• 3D map reconstructs electrical activation
• Ablation performed same session if appropriate

Treatment Pathways

Medical Management: Rhythm & Rate Control

Rate Control Strategy (for permanent AF or elderly):

• Goal: Keep heart rate 60-100 at rest, <110 with activity
• Medications: Beta-blockers (metoprolol, bisoprolol), calcium blockers (diltiazem), digoxin
• Advantages: Simpler, fewer side effects than rhythm control
• Anticoagulation mandatory for stroke prevention

Rhythm Control Strategy (for symptomatic AF, younger patients):

• Goal: Restore and maintain normal sinus rhythm
• Medications:
  • Class IC (flecainide, propafenone): First-line if no structural heart disease
  • Class III (sotalol, dofetilide, amiodarone): For structural heart disease; more side effects (thyroid, lung, liver with amiodarone)
• Pill-in-Pocket: Patient takes flecainide at onset of AF episode—restores rhythm in 2-4 hours (70% success)

For Other Arrhythmias:

• SVT: Beta-blockers; vagal maneuvers (Valsalva, carotid massage) abort acute episodes
• Ventricular ectopy (PVCs): Beta-blockers if symptomatic; no treatment if asymptomatic and <10,000/day on Holter
• Bradycardia: Stop rate-slowing medications; pacemaker if symptomatic or <40 bpm

Anticoagulation: Stroke Prevention in Atrial Fibrillation

CHA2DS2-VASc Score determines stroke risk (0-9 points):

• Congestive heart failure: 1 point
• Hypertension: 1 point
• Age ≥75: 2 points
• Diabetes: 1 point
• Stroke/TIA/thromboembolism prior: 2 points
• Vascular disease (prior MI, PAD): 1 point
• Age 65-74: 1 point
• Sex category (female): 1 point

Anticoagulation Recommendations:

• Score 0 (males) or 1 (females): No anticoagulation—low stroke risk
• Score 1 (males): Consider anticoagulation—discuss risks/benefits
• Score ≥2: Anticoagulation mandatory—stroke risk 4-8%/year untreated

Anticoagulant Choices:

• DOACs (Direct Oral Anticoagulants): Apixaban, rivaroxaban, dabigatran, edoxaban—fixed dosing, no monitoring, safer (less brain bleeds)
• Warfarin: Requires INR monitoring every 2-4 weeks (target 2-3); interacts with foods (green leafy vegetables) and many drugs—but cheap, reversible
• Aspirin is NOT adequate for AF stroke prevention—60% less effective than anticoagulants

Bleeding Risk Management:

• HAS-BLED Score estimates bleeding risk (hypertension, renal/liver disease, prior bleeding, elderly)
• High bleeding risk → address modifiable factors (control BP, stop NSAIDs, PPI for ulcer history), choose safest anticoagulant (apixaban)—do NOT withhold anticoagulation unless extreme risk

Catheter Ablation: Curative Therapy for Many Arrhythmias

Indications:

• SVT (AVNRT, AVRT, atrial flutter): First-line—95% cure rate
• Symptomatic paroxysmal AF failing medications: 70-80% success
• Persistent AF (continuous >7 days): 50-60% success; often needs repeat procedure
• Symptomatic PVCs with high burden (>10,000/day): Eliminates trigger

Procedure:

• General anesthesia or deep sedation
• Catheters via femoral vein (leg) reach heart
• Pulmonary vein isolation (PVI) for AF—electrical disconnection of pulmonary veins (AF triggers originate here)
• 3D electroanatomic mapping (CARTO, EnSite) creates real-time chamber reconstruction—guides catheter with millimeter precision
• Radiofrequency or cryoablation energy destroys abnormal tissue
• 3-5 hours duration; overnight observation; discharge next day

Post-Ablation:

• Blanking period (3 months): Arrhythmias may still occur due to inflammation—don't count as failure
• Continue anticoagulation 2-3 months (lifelong if CHA2DS2-VASc ≥2)
• Continue antiarrhythmics 3-6 months—discontinued if no recurrence
• Holter monitor at 3, 6, 12 months—monitor for silent AF recurrence

Complications (<1% major):

• Cardiac perforation, stroke, vascular injury, phrenic nerve damage (cryoablation)—rare but serious

Pacemaker Implantation: For Slow Heart Rates

Indications:

• Symptomatic bradycardia (<40 bpm) with dizziness, syncope, fatigue
• Complete heart block: Atria and ventricles beat independently—syncope risk
• Sick sinus syndrome: Pauses >3 seconds during sleep, inappropriate bradycardia with activity
• AF with slow ventricular response needing medications that further slow rate

Pacemaker Types:

• Single-chamber (VVI): Paces ventricle only—for chronic AF with bradycardia
• Dual-chamber (DDD): Paces atrium and ventricle—maintains AV synchrony, more physiologic
• Biventricular (CRT): For heart failure with conduction delay—improves pumping efficiency
• Leadless: Capsule-sized device implanted via catheter—no chest incision, no leads—limited indications (VVI pacing only)

Procedure:

• Local anesthesia + sedation
• Small incision below collarbone
• Leads threaded via vein into heart; anchored with screws or tines
• Generator (battery + computer) placed in subcutaneous pocket
• 1-2 hours; overnight observation; discharge next day

Follow-Up:

• Wound check at 1 week
• Device interrogation (check battery, lead function, pacing thresholds) at 1 month, 3 months, then every 6 months
• Battery lasts 8-12 years—replacement procedure simpler (keep leads, replace generator only)

Implantable Cardioverter-Defibrillator (ICD): Sudden Death Prevention

Indications:

• Secondary prevention: Survived cardiac arrest or sustained ventricular tachycardia
• Primary prevention:
  • Ejection fraction ≤35% despite optimal medical therapy (post-MI >40 days)
  • Inherited arrhythmia syndromes (long QT, Brugada, hypertrophic cardiomyopathy) with high-risk features
  • Non-ischemic cardiomyopathy with EF ≤35%

ICD Functions:

• Pacing: Treats bradycardia (like pacemaker)
• Cardioversion: Low-energy shocks for VT
• Defibrillation: High-energy shocks for ventricular fibrillation (cardiac arrest rhythm)

Procedure: Similar to pacemaker—larger generator, thicker leads. Tested during implant (induce VF, confirm ICD detects and shocks successfully).

Living with ICD:

• Avoid MRI (unless MRI-conditional device)
• Alert security at airports (device may trigger metal detectors)
• Driving restrictions—6 months after implant or shock (varies by region)
• Shocks feel like "kick in chest"—appropriate shocks are life-saving; inappropriate shocks (due to lead fracture, AF mistaken for VT) require urgent evaluation

Electrical Cardioversion: Immediate Rhythm Restoration

For persistent AF or atrial flutter:

• Synchronized DC shock under deep sedation (propofol)—90% immediate success
• Pre-requisites: 3 weeks anticoagulation OR trans esophageal echo (TEE) to rule out atrial clots
• Post-cardioversion: Continue anticoagulation 4 weeks minimum; lifelong if CHA2DS2-VASc ≥2
• Recurrence common (50% within 1 year) without antiarrhythmics or ablation

What to Expect: Your Care Journey

Initial Arrhythmia Consultation

• Detailed symptom history, physical exam (pulse, BP, heart sounds)
• 12-lead ECG; if normal, Holter or event recorder prescribed
• Labs ordered (thyroid, electrolytes, kidney function)
• Echo if not done recently
• Preliminary treatment plan—medications, anticoagulation if AF, discuss ablation if indicated

Follow-Up Visit (1-2 Weeks)

• Review Holter/event recorder data—arrhythmia identified?
• Echo results—structural heart disease?
• Finalize treatment plan:
  • Medical management → start medications, schedule follow-up
  • Ablation candidate → refer to EP cardiologist, schedule EP study + ablation
  • Device candidate → pre-op clearance, schedule pacemaker/ICD implant

If Ablation Planned (Week 4-6)

• Pre-procedure consult with EP cardiologist—review risks/benefits, procedure details
• TEE if AF ablation—rule out atrial clots
• Procedure day: NPO after midnight, IV sedation/general anesthesia, 3-5 hours procedure, overnight stay
• Discharge next day with medications, follow-up schedule

Post-Ablation Timeline

• Week 1: Wound check, groin hematoma surveillance
• Month 1: Device interrogation if pacemaker/ICD; symptom review
• Month 3: Holter monitor—check for silent AF recurrence; consider stopping antiarrhythmics if no recurrence
• Months 6, 12: Holter monitors; taper/stop anticoagulation if no AF AND low CHA2DS2-VASc score

Technology & Innovation

3D Electroanatomic Mapping: Precision Ablation

CARTO (Biosense Webster) and EnSite (Abbott) systems create real-time 3D reconstructions of heart chambers with sub-millimeter accuracy. Voltage maps identify scar tissue (arrhythmia substrates); activation maps show electrical wavefronts—"GPS for the heart".

Advantages:

• Reduced fluoroscopy (X-ray)—safer for patients, especially women of childbearing age
• Higher success rates—precise lesion placement
• Shorter procedures—faster mapping

Intracardiac Echocardiography (ICE)

Real-time ultrasound from inside the heart—visualizes catheter tip, identifies anatomic landmarks (esophagus, phrenic nerve), monitors for complications (pericardial effusion). Essential for complex AF ablations.

Preventing Complications

Untreated arrhythmias can cause:

• Stroke: AF without anticoagulation—15% stroke risk over 5 years; devastating disability
• Sudden Cardiac Death: Ventricular arrhythmias in high-risk patients (low EF, inherited syndromes)
• Heart Failure: Chronic rapid AF (>110 bpm) causes tachycardia-induced cardiomyopathy—EF drops over months
• Syncope & Injury: Bradycardia, heart block without pacemaker—falls, fractures, head trauma

Our Prevention Strategy:

• Zero missed AF in palpitation workup—extended monitoring captures intermittent episodes
• Aggressive anticoagulation adherence—pharmacy refill tracking, INR coordination for warfarin
• Timely device implantation—no delays for symptomatic bradycardia or high sudden-death risk
• Ablation offered early—before chronic AF leads to atrial remodeling (harder to ablate)

Why Ajuda for Arrhythmia & Electrophysiology?

Take the First Step

Heart rhythm problems deserve expert care—from benign palpitations needing reassurance to life-threatening arrhythmias demanding urgent intervention. If you're experiencing irregular heartbeat, fainting, or living with atrial fibrillation, schedule a comprehensive arrhythmia evaluation today.

Book Your Consultation: Call 9010550550 or WhatsApp for appointments Mon-Sat, 9 AM-6 PM. Urgent cases seen same-day.

Early diagnosis and treatment prevent stroke, sudden death, and heart failure. Let Ajuda Hospitals restore your heart's natural rhythm with cutting-edge electrophysiology care.