Do's and Dont's

Do’s

-       Keep and follow your medical appointments. Bring your medication along as it helps ensure the doctor on what medication you are taking.

-       Follow the doctor’s instructions when consuming any medication. Be it, over-the-counter medicine, cold or flu tablets, and nutritional supplements.

-       Mention all your side effects from any medication consumed. For example, the feeling of depression and palpitations.

-       If you are having an arrhythmia symptoms, a new symptom or the symptom worsen, inform the doctor.

-       Take care of yourself. Lie down if you are feeling light-headed.

-       Consume a healthy diet. Most arrhythmia cases are caused by underlying heart diseases. Have a diet that consist plenty of fruits, vegetables, and whole grains. Commit to physical activities regularly.

-       Consume healthy fats. As an example, olive oil, seeds and nuts. Omega-3s are found in foods like tuna, sardine, salmon and flaxseeds.

Don’ts

-       No smoking.

-       Caffeine, alcohol and substances that can trigger arrhythmia. Caffeine is closely associated with arrhythmia-particularly with fast heart beat

-       Eat food that are high in sodium. Salt increases blood pressure, which will then increases the chances of having arrhythmia. Limit yourself to not consume more than 1 5000 milligrams of sodium a day.

-       Keep away from animal fats.

-       Foods that are high in tyramine. Tyramine is a substance that are found in aged and fermented foods. A few examples are aged cheeses (Cheddar), cured meats (dry-type summer sausages), fermented cabbage (kimchee), certain sauces (soy sauce) and yeast extract spreads (Marmite). 

From the dos and don’ts patients can apply another health behaviour theory can be applied to enhance adherence, for instance the transtheoretical model for stop smoking or  stop consuming excessive amount of coffee or stop eating high-calorie foods. All of those are the triggers of arrhythmia, thus it needs to control and stop.  Let’s take coffee as an example; the patient will start at the pre-contemplation stage, where he/she has no intention of stopping his/her excessive intakes of coffee. Then he/she will start to feel that there is fluttering action of his/her heart and realizing that the excessive amount of coffee is the cause. This is the stage when he/she starts to contemplate and wants to stop drinking too much coffee. The next stage is preparation, he/she will prepare a coffee flavoured sweets, which contains only a small amount of caffeine, or a chewing gum to replace coffee. Then the action stage, he/she may decrease the number of cups that he/she takes every day for example, only one cup per day and to be taken only during breakfast is to be accomplished in a month time. Then improve on the progress made by drinking only five cups a week, only on weekdays. Lastly, he/she should maintain with drinking 5 cups of coffee during weekdays for every week, while trying to avoid tempting situations. 

A Case Study on Heart Skips

Arrhythmia Statistics

            Based on the statistics by the American Heart Association, there are 4 300 000 Americans that are diagnosed with Arrhythmia and 630 000 of them are admitted annually. The most common kind of Arrhythmia is the Atrial Fibrillation, where 2.2 million Americans are diagnosed with that disease. 70% of people having Atrial Fibrillation are between the ages of 65 to 85. Per year, there are more than 250 000 deaths per year caused by Ventricular Fibrillation. 

Case Study

            This case study is about Roger, who is 58 years old and he had Atrial Fibrillation. Atrial Fibrillation is a type of fast heart beat arrhythmia (Tachycardia). It is the most common type of arrhythmia and it is when your heart does not pump regularly or work as properly as it should. This causes a “fluttering” heart beat, irregular pulse and in Roger’s case, having severe chest pains. He felt a lot of nerve activity in his chest area. At first, the pain was only temporarily but as time goes by, the symptoms increased and lasted longer. After five months, he could not take the pain and decided to see his general practioner. His GP’s first reaction was he taught that Roger is having a problem. Roger was taken aback as his family has no history of any heart problem or diseases related to the heart. His first question was, “how could that even be?”. His GP then recommended him to make an appointment with a heart specialist at a hospital.

            Within the next eight weeks, he met a heart specialist. Roger then proceeded by showing all his medical records and check-ups with is GP.  The heart specialist first reaction is that his heart problem could be related to a heart rhythm disturbance.

            By the following month, he had two Electrocardiograms (ECG), Echocardiogram, and a seven-day event recorder. After the next meeting with the heat specialist, it is then confirmed that Roger is having Arrhythmia and it is due to Paroxysmal Atrial Fibrillation. Paroxysmal Atrial Fibrillation is when electrical signals in an individual’s heart causes the heart to beat rapidly and it just stop on its own (Case-Lo, 2013). At first, the heart specialist prescribed medication to lower his blood pressure but it did have very little positive effects on him. He was then given anti-arrhythmic medication and beta-blockers. He felt good for the first ten days as he did not experience any symptoms. Sadly, these medication made Roger feel very tired and was unable to perform his daily activities and his job. Besides that, he kept a diary to jot down he felt every day since the change of medication. It was also to track his Atrial Fibrillation episodes over the months and tried various medication of the different dosage. Although with all the medication, he was still experiencing the symptoms even after meeting the heart specialist eight months later. So he got another medication and this time, he felt a lot of positive effect on him. It made a big and fast improvement in Roger. Again, the medicine was also effective for a short period of time and the symptoms kept coming back days after that. The heart specialist then asked him to refer to a hospital that has an Electrophysiological Cardiologist.

            An Electrophysiological Cardiologist are qualified to perform special tests on an individual’s heart electrical system (Orenstein, 2011). For an example, electrophysiology study or an ablation and these was what the Electrophysiological Cardiologist suggested Roger to go through. He explained that is has a 70% probability of being a success. Roger agreed and was ask to be on the waiting list for the procedure. His medication was changed to the previous anti arrhythmic medication hoping that the effects would last longer but he was still having symptoms and every day became a struggle for him.

            Roger received a letter from the hospital with the date arranged for him to undergo the procedure. A week before the date of the procedure, he was asked to be at the hospital for a pre-admission check-up and give a 45 minute information session about the procedure. A week later, he arrived to the hospital for a procedure called Pulmonary Vein Isolation. He was given medication to relax him and the procedure lasted for three hours.

            After the procedure, he was sent to a special care unit to recover for the first few hours after the procedure. His recovery was good and uncomplicated and the doctors allowed him to go back the next day. Roger had home rest for the first two weeks and still have to take his medication for the next eight weeks.

            Even years after the procedure, his symptoms decreased and he is much better now. He still takes his medicationn to control his high blood pressure but now he only goes to the hospital annually for a review after the procedure. His symptoms then completely subsided.

How to fix the heart skips?

Bradycardia: Artificial Pacemaker

figure 1.  Artificial Pacemaker placement

For bradycardia patients, doctors usually hold off any medications that slows their heartbeat, and treat the conditions by implanting a permanent or temporary pacemaker (Arrhythmia Alliance, 2012). An artificial pacemaker is a small battery operated device, that is approximately the size of a fifty pence piece, used to detect and fires a small electrical impulse to stimulate the heart wall to make it contract and to make the heart beats. It is planted just under the skin of your chest (below your collar bone) and insulated lead wires that connects to the pacemaker are attached to the heart to help your heart muscle pump blood regularly (National Heart Foundation Australia, 2015;Adelaide-Meath National Children's Hospital, 2015) . The lead also provides the information on the heartbeat’s natural activity. The body will not reject artificial pacemaker.

Tachycardia: Vagal Maneuvers, Cardioversion, Catheter Ablation and Pharmacological Medications

Vagal maneuver is a set of physical activities that stimulate the Vagus nerve, the nerve serving the structures of the chest, abdomen, head and neck, which supplies parasympathetic impulses to the myocardium (heart muscle) and trigger the release of acetylcholine to put halt on the conduction of electrical impulses and decrease the rapidity of the heart (Healthwise Staff, 2012;Wang & Estes, 2014). The maneuvers are gagging, holding your breath and bearing down (Valsalva maneuver), immersing your face in ice-cold water (diving reflex), coughing and Carotid massage (neck massage). 

figure 2. Cardioversion

Cardioversion uses electrode patches to deliver a split-second energetic shock to the heart muscles while the patient is sleeping, the shock applied will interrupt the abnormal heart rhythm and return a normal heartbeat (Intermountain Healthcare, 2011;Texas Cardiac Arrhythmia Institute, 2015;Tandri, 2015). This quick procedure may need to be repeated to effectively restore a normal heart rhythm under the direction of a team of highly trained doctors, nurses and technologists in the electrophysiology lab (Intermountain Healthcare, 2011). 

figure 3. Catheter Ablation

Catheter ablation uses radiofrequency energy to destroy (ablate) a small area of the tissue of the heart which is causing arrhythmia. Guided with x-rays, the doctor will insert several small catheters (thin, flexible tubes) through the veins in the groin or neck and direct them to the tissues that interrupt the heart’s electrical activity then thermal energy (extreme heat) or cryoenergy (extreme cold) energy will be emitted to the problematic tissues through one of the catheters (National Institute of Health, 2012;American Heart Association, 2014;Cleveland Clinic, 2015;Ashikaga, 2015). This energy also disconnects the electrical pathway of the abnormal rhythm.

There are three main pharmacological drugs being prescribed to an arrhythmic patient, they are the anti-arrhythmic drugs, the calcium channel blockers and beta-blockers (American Heart Association, 2014;Healthline Networks, 2015). Anti-arrhythmic drugs either cease the abnormal transmission of electrical impulses send by the natural pacemaker tissue that is firing too fast to the heart tissues (American Heart Association, 2014). The drugs are in a form of pills or in a form of intravenous (IV) drip, they work to correct and restore the normal rhythm of the heart. Next is the calcium channel blockers, which is also known as "calcium antagonists." Calcium is an electrolyte that functions as the heart regulator, imbalance of calcium will cause arrhythmia. Thus, calcium channel blockers work by blocking the movement of the calcium electrolytes into the heart and blood vessel tissue (Healthline Networks, 2015). It can be taken in a form of pill or in a form of intravenous (IV) drip. Lastly, beta-blockers, which is also known as ‘beta-adrenoceptor blocking’ that blocks adrenaline hormones from stimulating rapid firing of electrical impulses to the heart tissues, thus results in a decrease of heart beats, reduction of cardiac stress output and lessening of the arterial blood pressure (Healthline Networks, 2015).

Bradycardia and Tachycardia: Implantable Cardioverter Defibrillator (ICD) and Surgeries

           

figure 4. ICD

Implantable Cardioverter Defibrillator (ICD) monitors the heartbeat constantly and automatically will detect any irregular heart followed by a short electrical shock to the heart to sustain a normal heart rate (Cheng, 2015). The shock is generally expressed by patients as being “kicked in the chest,” as it gives a momentary chest pain. The device must be check and/or replaced every four months. It consists of a titanium-encased pulse generator (the size of a small box of raisins) that contains a lithium battery and electrical circuitry and capacitors attached to one, two or three leads (wires) that are inserted into the heart and it is implanted under the skin beneath the collarbone (Cheng, 2015).

            Two of the main surgeries for treating arrhythmia are the maze procedures and coronary artery bypass grafting (CABG) surgery  (University of California San Francisco, 2015). Maze surgery treats arrhythmia by making small cuts or burns in the heart tissues that will prevent the transmission of abnormal electrical signals or by making a "maze" of new electrical routes to let electrical impulses move easily to the heart tissues (Texas Heart Institue, 2015;University of California San Francisco, 2015). CABG is when a healthy artery or vein is extracted from other parts of the body grafted in between the blocked coronary artery, thus creating a new route for blood to move to the heart tissues (National Institute of Health, 2012).

Adherence to Medical Advices and Preventive Measures

The most important part that an arrhythmic patient needs to adhere is to follow the timeliness of the medicated drug prescribed and to check the functionality of the planted devices if they previously underwent those procedures. This is to prevent arrhythmia to advance into a heart attack or a stroke.

As for the medication, the patient can monitor their consumption by relying to the device called Medication Event Monitoring System (MEMS). MEMS is a tracking medication usage device without any active patient input. It consists of an electronic memory integrated into a cap designed to fit a normal medicine bottle, it records the number of act on when the cap is opened to remove a pill (Brannon & Feist, 2014).

The health belief model can also be applied, from the previous consultations with the doctors; patients should already know the fact that they are susceptible in getting a heart attack or stroke as they are already arrhythmic. With that they will come to acknowledge the severity of getting a heart attack or stroke. Following that, they would search and take the initiative to know more on how to improve their conditions and to maintain it that way, in which it is their way of perceiving the benefits of health-enhancing behavior. Lastly, knowing their limits for the level of exercising or kinds of foods that they can eat without reaching the excess point is their way of perceiving barriers towards the health-enhancing behaviors (Brannon & Feist, 2014). For example, exercising too much may cause their heart to beat faster than usual or eating too much omega-3 rich foods may cause electrolyte imbalance.

Types Of Skipping Beats

Arrhythmia divided into two categories which is the ventricular arrhythmia and supraventricular arrhythmia, (Texas Heart Institute,2015). The ventricular arrhythmia take place in the lower chambers of heart termed the ventricles. Meanwhile, supraventricular arrhythmia take place in the area above the ventricles termed the atria. The Bradycardia means that the heart beats is too slow and the Tachycardia means that the heart beats too fast. 

Bradycardia

figure 1. Bradycardia

 Bradycardia is a slow heart beat which is less than sixty beats per minute. This condition occurs when the electrical impulse that signals the heart to contract is not formed in the heart’s natural pacemaker which is the sinoatrial node, or it is not sent to the ventricles, (University Hospital Southampton,2015). This type of arrhythmia usually affects elderly people, but there are chances to affect young generations as well. This condition is caused by any one of two factors which is the central nervous system does not signal that the heart requires to pump more or it could be due to the damage of sinoatrial node. The damage of sinoatrial damage could be associated to aging, congenital defects, heart diseases or medicines that is taken to control high blood pressure and arrhythmia.

Tachycardia 

 

figure 2.  Tachycardia

Tachycardia is a fast heart beat which is more than 100 beats per minute. There are few types of tachycardia which depends on where the fast heart beat originates, (Mayo Clinic, 2015). If the fast heart beat originates in the ventricles, it is called the ventricular tachycardia. Meanwhile, if the fast heart beat originates above the ventricles, it is called the supraventricular tachycardia.

Ventricular Arrhythmias 

In ventricular arrhythmias it consists of Ventricular Tachycardia, Ventricular Fibrillation, and Premature Ventricular Contractions, (Texas Heart Institution, 2015). . The ventricular tachycardia is a state in which the sinoatrial node no longer controls the pounding of the ventricles and the pacemaker’s role is being taken by the other parts alongside the lower electrical pathway. Since the signal does not move through your heart muscle along the usual route and this condition causes the heart muscle does not beat normally. Thus, this condition would make a person feel as if their heart skip beats and this rhythm cause severe shortness of breath, syncope or fainting. 

Ventricular Fibrillation 

figure 3.  Ventricular Fibrillation

The most serious type of arrhythmia which results from an uncontrolled and irregular beat. A person who suffers from ventricular fibrillation would have numerous impulses that arise at the same time from various locations, (American Heart Association,n.d.). The heartbeat sometimes could reach about 300 beats per minute and may face chaotic heartbeat which means a very little amount of blood is being pumped from the heart to the brain and body and might result in collapsing. Apart from that, individuals who have history of heart attack or heart disease have a high risk of getting ventricular fibrillation. 

Premature Ventricular Contractions

Premature Ventricular Contractions also known as Premature Ventricular Beat is a less serious sort of ventricular arrhythmia. According to Kulick and at el. (2015), this condition occurs when ventricles contract rapidly out of order with the regular heartbeat. Normally there is no treatment is needed for this condition but if the individual have a history ventricular tachycardia or heart disease, it might cause a serious type of arrhythmia. This condition could be caused by caffeine and over-the-counter cold and cough medicine. 
 

Supraventricular Arrhythmias

In supraventricular arrhythmias it consists of Supraventricular Tachycardia also known as Paroxysmal Supraventricular Tachycardia, Atrial Fibrillation, Wolff-Parkinson-White Syndrome, and Postural Orthostatic Tachycardia Syndrome, (Texas Heart Institution, 2015). The supraventricular arrhythmia is a state where it originates in the locations above the heart’s lower chambers which is the atria or the atrial condition pathways. This condition, may or may not need treatments and it might be caused by caffeine, alcohol, tobacco or cold and cough medicines. Moreover, this condition would symptoms such as heart palpitations, shortness of breath, chest tightness and a very fast pulse rate. 

Supraventricular Tachycardia or Paroxysmal Supraventricular Tachycardia 

figure 4.  Supraventricular Tachycardia

 The supraventricular tachycardia is a condition where regular and rapid heart rate from 150 to 250 beats per minute which beats in the atria. Meanwhile, in the paroxysmal supraventricular tachycardia the word paroxysmal means irregularly or from time to time. This condition occurs when the electrical signals in the heart’s upper chambers fire peculiarly, which interferes with the electrical signals that comes from the sinoatrial node and the beats in the atria eventually speeds up the heart rate, (John Hopkins Medicine, n.d.). This condition normally common among infants, young people and most likely to happen in anxious youngsters, women and individuals who are very worn-out. Other than that, chain smokers, alcoholic and individuals who takes coffee regularly have a higher risk.

Atrial Fibrillation 

figure 5.  Atrial Fibrillation

The atrial fibrillation is a fast and irregular rhythm in which single muscle fibers in heart contract or twitch, (National Health Service, 2015). This condition might cause the blood to pool in the heart’s upper chambers and the pooled blood could lead to blood clot. Once the blood clot travels from the heart and blocks the smaller artery in the brain, stroke might take place. Thus, when an individual with atrial fibrillation suffers from stroke, they may need antiplatelet therapy which could prevent the formation of blood clot and causes stroke. 

Wolff-Parkinson-White-Syndrome 

figure 6. Woff-Parkinson-White-Syndrome pathway

 The Wolff-Parkinson-White (WPW) syndrome is a cluster of abnormalities caused by additional muscle pathways amid the ventricles and the atria, (John Hopkins Medicine,n.d.). This pathways cause the electrical signals to reach at the ventricles too quickly, and the signals are sent back to the atria. Thus, it resulted a very fast heart rate. Individuals with this syndrome might have symptoms such as dizziness, episodes of fainting, chest palpitations and they are most likely to have episodes of paroxysmal supraventricular tachycardia. 

Postural orthostatic tachycardia syndrome

figure 7. Effect of POTS to the body

 Generally, when an individual stands up, the body makes any desirable changes to compensate for the gravitational stress of adjustment in body posture, (Dysautonomia International, 2012). In order to keep the oxygen-rich blood flow to the brain and the upper body, the heart rate increases and the blood vessels in the lower part of body tighten. For some individuals, this does not occur and affect their capability to stand or continue standing. This is called the orthostatic intolerance. The postural orthostatic tachycardia syndrome is a type of orthostatic intolerance. The patients with this condition, the blood vessels in the lower body do not tighten when they are standing because

of the gravity causes more blood to flow than normal moves to the lower body. Individuals with this condition may have symptoms such as blurry vision, fatigue, headaches, lightheadedness and fainting. 

Heart Block 

figure 8.  Heart Block

 The Heart block occurs when the sinoatrial node sends its electrical signal appropriately, but the signal is not sent via the atrioventricular, (Texas Heart Institute,2015). The condition is most likely caused by aging or by the scarring or swelling of the heart which at times results from the coronary artery disease. Moreover, it could be caused by the cardiac amyloidosis, that is a condition where the amyloid deposits take of the regular heart muscle. 

According to National Health Service (2014), there are few types of heart block, and named according to the degree of severity.

First-Degree Heart Block. 

figure 9.  First-Degree Heart Block

 The first-degree heart block means that the impulses are travelling via the atrioventricular node too slowly.

Second-Degree Heart Block

The second-degree heart block means that the impulses are moving via the heart's atria but are deferred in the atrioventricular node. Due to this delay the ventricles do not beat at the right time.

Third-Degree Heart Block

The third-degree heart block means that no impulses are reaching to the ventricles. In order to make-up for this, the ventricles use its own backup pacemaker by way of its slower rate. As a gap

in time is probable to happen among the impulse from the atria and the impulse from the backup pacemaker in the ventricles, an individual might faint. This situation is known as a Stokes-Adams attack. The third-degree heart block is very severe and could lead to heart failure or death.

Got Symptoms? What To Do Next?

Once the patient reported that they have all the symptoms, they then will be referred to a Cardiologist for further checkup and diagnosis to determine that if they suffer from arrhythmia. The patient will undergo series of diagnosing process such as:

Blood Test 

figure 1. Blood is drawn from a patient

 Blood will be drawn from their vein and sent to lab to check the level of substances in the blood such as potassium. Potassium is an electrolyte that sends electrical impulses in the heart for them to beat and pump the blood throughout the body (University of Maryland Medical Center, 2015). High level of potassium increases the chances of getting an arrhythmia because it sends excessive electrical impulses (Nhs.uk, 2015). 

Electrocardiogram (ECG) 

figure 2. Patient undergoing ECG

This is a standard cardiology tool for recording heartbeats and its rhythm. It uses electrodes that act as a sensor to detect the electrical activity of the heart. These electrodes are attached to certain parts of the chest. Patterns seen on the ECG could tell if there is a presence of arrhythmia through the irregular waves that the heart created (Heartrhythmcharity.org.uk, 2015). 

Holter Monitor 

figure 3. Holter Monitor with ECG reading

This is a portable ECG device that the patient attaches to their chest and it records the patient’s heart rhythm as they go through their daily routine. They are asked to wear this device for a day or more to see if they need to undergo more tests before the cardiologist finally could determine what kind of treatment or medication that they need (Heart.org, 2015). 

Event Monitor 

figure 4. An event monitor placed on patient

 

figure 5. Example of Event monitor

This portable device has a similar function like a Holter Monitor, but the only difference is that the patient will be asked to press a button on this device if they experience arrhythmic symptoms so the cardiologist could check the heart rhythm at the time of the symptom occurred (Bcpa.co.uk, 2015). 

Echocardiogram 

figure 6. Patient being diagnosed

This is another type of cardiology tool. It is a noninvasive test that uses sound waves to produce images of the patient’s heart’s size, structure and motion by placing a transducer, a hand-held device on the chest (Mayoclinic.org, 2015). 

Ambulatory Electrocardiogram

This device has a similar function as the Holter Monitor, where it tracks the heartbeat of the patient but it is used only for 24 hours (WebMD.com, 2015) 

If the arrhythmia did not show up during those tests, the cardiologist will try to trigger the arrhythmia using as follows:

Stress Test 

figure 7.  Patient being assessed

During a stress test, the patient will be asked to run on a treadmill or ride a stationary bicycle as their heart activity is being monitored. The cardiologist may use a drug instead to stimulate the heart in a way that is similar to exercise if the cardiologist found out that the patient’s coronary artery disease caused the arrhythmia, and they appeared to have a difficulty in exercising, (Nhs.uk, 2015). 

Tilt Table Test 

figure 8.  Process of Tilt Table Test

This type of test is only used if the patient had a near fainting spell. The patient will be laid flat on a table as their heart rate and blood pressure are being monitored. Along the way, the table will be tilted to a standing position. The cardiologist will observe how their heart and nervous system respond to the change in angle (Nhs.uk, 2015). 

Electrophysiological Testing And Mapping. 

figure 9. Placement of Catheter in the heart

figure 10.  Electrophysiological test and Mapping in process

In this test, the cardiologist will insert a thin thread, flexible tubes called catheter that are tipped with electrodes through the patient’s blood vessels that are connected to variety spots in their heart. The electrodes are used to map the spread of electrical impulses throughout the patient’s heart. The cardiologist may also use the electrodes to stimulate the patient’s heart to beat at rates that may trigger or halt an arrhythmia. This enables the cardiologist to see the location of the arrhythmia and determine what may be causing it (Nhs.uk, 2015).

How To Know If Your Heart Skipped A Beat?

Arrhythmias can produce a broad range of symptoms, from barely perceptible to cardiovascular collapse and death. When the arrhythmia occurs for longer time that it affects the normal functioning, a more serious symptoms other than the irregular heartbeat, may develop such as: (1) fatigue where they may experience extreme tiredness (Merriam-webster.com, 2015), (2) dizziness where they experience a whirling sensation in the head that may cause them to lose balance (Nhs.uk, 2015), (3) lightheadedness where they feel dizzy and feel that they are about to pass out, fainting or near fainting spells where they experience temporary loss of consciousness (Heart.org, 2015), (4) shortness of breath where there is the presence of sensation that they need extra effort to breath (Schueler, 2015) and (5) chest pain. In a worst-case scenario, they may collapse and have sudden cardiac arrest. Cardiac arrest is when someone collapsed in a sudden, is not breathing normally and irresponsive because their heart suddenly stops pumping blood to the whole body (Heart.org, 2015).

What is the cause for your heart to skip a beat?

Risk factors are not the immediate cause for a disease, it is a promoter, initiator, and the trigger for the occurrence of the disease (Bonomo & Araujo, 2012). As for arrhythmia, there are a number of cause for it to happen for instance, having coronary artery disease, electrolyte imbalance in the body (lack or an excess of sodium and potassium), changes in heart muscle, injury from heart attack and healing after heart surgery (WEbMD, 2015). The factors leading to these causes are the risk factors for arrhythmia. The risk factors are the socioeconomic status, social support, age, gender, Type A Behavior Pattern (TABP), stress, Tako-Tsubo syndrome and depression (Rozanski, Blumenthal & Kaplan, 1999).

Socioeconomic Status (SES)

Socioeconomic status determined the education, behavior and the cleanliness of the daily life. According to a research done by Rozanski in 1999, low socioeconomic status has a correlation with unhealthy behaviors and this increases the risk of having coronary artery disease, which is one of the cause of arrhythmia. In addition to that, low income restrict the health services they can get, lack of education resulted in difficulties to adhere medical prescription and lack of the consumption of nutritious foods. All these increases the potential of getting a coronary artery disease and also electrolyte imbalance in the body, in which both are the causes of arrhythmia.

Social Support

A population survey done in America found that a significant relationship between coronary artery disease and social support (Frasure-Smith & Lasperance, 1998). Social support is the support you receive from friends, family and special people that care for you (Towey et al.,

2013) and inhibition from social support may lead to the causing factors of arrhythmia. Another research done by Berkman and Syme (1979) reported that the number of social ties correlates with the mortality rate and the mortality caused by coronary artery disease was significantly related to the lack of social support. Social support prevent the engagement of risky behaviors and biologically, it can decrease the arterial pressure and cardiac response during stress (Bonomo & Araujo, 2012).

Age

Age is the major risk factor for arrhythmia. This is because there is a decline in cardiac functionality throughout the physiological aging (Bonomo & Araujo, 2012). It was reported that out of a sample between the ages of 60 to 85 years old, 80% of them had ventricular arrhythmia and 88% of them had supraventricular arrhythmia (Bonomo & Araujo, 2012).

Gender

Both male and female have equal risk for arrhythmia but male are more prominent in the analysis of most researches (Eaker, 1998). This is due to the biological differences between genders in terms of hormonal composition, genetic inheritance and the cerebral structure and functions. As for females, the pre-menopausal effect of estrogen protect them from the risk of having coronary diseases (Bonomo & Araujo, 2012). Thus protecting them from arrhythmia too.

Type A Behavior Pattern (TABP)

Type A behavior pattern is a set of behaviors of a person when confronting a challenging event (Bonomo & Araujo, 2012). The characteristics are hostility, competitiveness, impatience, rapidity and lack of attention to fatigue and sickness (Rozanski, Blumenthal & Kaplan, 1999). People with this behavior pattern experiences stress and thus affecting their cardiac activity and increases the arterial pressure. Their inattention towards fatigue may also cause a biological haywire such as platelets aggregation and intense discharge of the hormone catecholamine (Bonomo & Araujo, 2012). Platelets accumulation may cause the formation of plague in the artery which leads to coronary artery disease (Brannon, Feist & Updegraff, 2014) and the hormone catecholamine increases the heart beat in which will cause arrhythmia.

Stress

Stress is another major risk factor for arrhythmia. The frequency of stressful events determined the risk of heart diseases (Frasure-Smith & Lasperance, 1998). For example, the stress from work will activate the sympathetic nervous system and promote the increment of cardiac rate and arterial pressure, and lower the ejection of blood from the heart (Bonomo & Araujo, 2012). This will interrupts the cardiac activity and functionality and eventually cause arrhythmia.

Tako-Tsubo Syndrome (Broken Heart Syndrome)

Tako-Tsubo syndrome which is caused by the pressure in the apex of the ventricle of the heart due to two factors; hormonal imbalance and stressful events (Bonomo & Araujo, 2012). This causes a person to have a symptom of chest pain. This syndrome generally affects women after menopause who undergo some stressful episodes. Continual application of pressure on the ventricle causes irregular heart beat which is arrhythmia (Bonomo & Araujo, 2012).

Depression

Depression is the feeling of sadness, loneliness, hopelessness, guilt and shame (Kubzansky & Kawachi, 2000). Depression causes hormonal imbalance and inhibition from social support thus leading its way to coronary and cardiac problems. A study by Lane (2005) reported that 16% of the patients diagnosed with moderate and severe depression experienced cardiac events and he found that depressed patients have two times higher risk of getting