Cardiac arrhythmias are any disturbances of normal heart rate and rhythm. The incidence of heart arrhythmias in the general population ranges from 1.5 to 5%. Increased age is a noted risk factor for increased incidence of cardiac arrhythmias. According to the Centers for Disease Control (CDC), atrial fibrillation (AF) is the most common heart rhythm disorder.  The prevalence of AF in individuals between the ages of 40 and 65 years is 2.3% and in those individuals over the age of 65 years it is 5.9%. Approximately 70% of individuals with AF are between 65 to 85 years of age. In numerical terms, the incidence of AF in the United States is 1 in 50 people under the age of 65 years and 1 in 10 over the age of 70 years.¹

Heart rate is the number of heart contractions that occur in the human body per minute. The normal heart rate is determined to be between 60 to 100 beats per minute at a normal physiological resting state. And yes, there can be exceptions to the rule. A heart rate of less than 60 beats per minute is abnormally slow and is called bradycardia. A heart rate greater than 100 beats per minute is abnormally fast and is called tachycardia.¹

Heart rhythm is the pattern of myocardial contractions over time. The synchronicity of heart contractions relative to other contractions determines normal heart rhythm. Any disorder of the synchronicity of heart beats can lead to a heart rhythm disorder. And yes, not all heart rhythm disorders are considered pathological. For instance, respiratory sinus arrhythmia is a variation in heart rate and rhythm that occurs with normal inspiration and expiration. The occurrence of cardiac arrhythmias is also highly variable. They can occur gradually or suddenly and be paroxysmal or persistent.  They can also be asymptomatic or symptomatic. They can also be benign and irritable or serious, harmful and life threatening.¹

Heart palpitations are an abnormal sensation of the heart beating in the chest.  The palpitations have been described as a fast-beating heart, pounding or fluttering. Most heart palpitations are benign and not life threatening and are triggered by stress, hormones, caffeine and other lifestyle and nutritional factors. Atrial fibrillation on the other hand, is a serious heart arrythmia that can have deleterious consequences. The persistent occurrence of AF dramatically increases the risk of blood clots and strokes. The incidence of strokes is 3.1% of the general adult population in the US. Having AF dramatically increases your risk of having an ischemic stroke by 5 times. And also, ventricular arrythmias can have life threatening consequences.¹

Normal heart rhythm is also called normal sinus rhythm. The Sino-Atrial or SA node in the upper right atrial chamber begins the normal heart rhythm by generating an electric impulse that travels downward and across both atria causing atrial contraction. The impulse then travels to the septal wall separating the atria from the ventricles to specialized contractile cells called the Atrio-Ventricular or AV node. The AV node acts as a stopgap slowing down the atrial impulse. The impulse is then conducted to the Bundle of His below the AV node and then to the right and left bundle branches that transcend the entire right and left ventricle musculature. Small, short branching Purkinje fibers branch out from the right and left bundle branches to the width of the ventricular myocardium and deliver the impulses that cause muscular contraction.¹

Arrythmias that originate in the atria above the AV node and are tachycardic are called supra-ventricular tachycardia or SVT.  The four main types of SVT’s include atrial sinus tachycardia, re-entrant tachyarrhythmias, atrial flutter and atrial fibrillation. Arrhythmias that originate below the AV node and are tachycardic include ventricular tachycardia or VT. The two main types of VT’s include ventricular tachycardia and ventricular fibrillation. A premature ventricular contraction or PVC is a relatively benign not tachycardic ventricular arrhythmia that is often felt as a heart palpitation.¹

I have a particular penchant for the study of naturopathic cardiology. In fourth year naturopathic medical school at Bastyr College in Seattle, our cardiology course was taught by an attentive practicing internal medicine specialist. She was informed, prepared and taught the course well.  I found the study of the heart and circulation interesting. One of the required textbooks for the course was the Rapid Interpretation of EKGs by Dr. Dale Dubin, the short classic softcover book that established logical guidelines for viewing and interpreting electrocardiograms. The mantra “rate, rhythm and axis” is the foundation of electrophysiologic cardiac evaluation that he expounded. I still refer to the book over thirty years later.

Precepting was a part of that naturopathic medical education program whereby a third or fourth year student shadows and follows a skilled practitioner to gain experience and knowledge. I had the good fortune of preceptoring with an old and wise cardiologist named Dr. Gillis in the Kitsilano suburb of Vancouver. He had a small office on the second floor of a building where he practiced outpatient cardiology. He had a simple automated treadmill, a plain electrocardiogram and blood pressure monitor, whereupon he would do treadmill testing for evaluation of cardiac ischemia. I followed him as he interviewed and evaluated patients and learned a great deal from him about the assessment of cardiac arrhythmias.

One of most practical and useful medical office devices that I have used was an inexpensive handheld electrocardiogram that I purchased off eBay.  I have used the device liberally on many patients as part of our general assessment. It gives a quick and albeit simple view of heart rate and rhythm without applying EKG leads to the chest. Obviously, it does not replace a standard 3,6 or 12 lead EKG and its reliance for diagnostic interpretation is limited. It is nonetheless fun to play with. It shows the standard lead I EKG waveforms including P, QRS and T waves. It is reliable for assessing heart rate and shows patterns that might indicate disturbances of heart rhythm. I have observed different wave forms and rhythm patterns that appeared to be abnormal. I would often quickly refer to Dr. Dubin’s book for insight into explanation of the EKG pattern viewed. And surprisingly I have viewed many abnormal cardiac electrophysiologic patterns. I have been able to view bradycardia, tachycardia, supraventricular tachycardias, bundle branch blocks and premature ventricular contractions. I have even sent some patients directly for cardiac assessment based in part of the observation and interpretation of the patterns viewed with this handheld EKG device.

The Valsalva maneuver was named after the 17^th century Italian physician who popularized the use of this technique. The Valsalva maneuver is a technique to increase intrathoracic pressure on the heart which leads to a decreased preload in heart chambers. Baroreceptors are then stimulated along with other compensatory mechanisms that decrease specific heart functions in response to the decreased preload. A slowing of SA node activity and heart rate then occurs. The maneuver has been described as forcing air out of the lungs against a closed epiglottis valve. Other descriptions include holding your breath and bearing down as if you are trying to have a bowel movement, blowing a big balloon with air or pushing against a stationary wall with your chest muscles contracted. The technique is repeated for several times for six to twelve seconds each. The maneuver can help to break sympathetic stimulation to the excitable heart tissue. The maneuver is a relatively safe and benign, although syncope, and dizziness can occur.²

The carotid sinus massage is a technique that may be used to help ameliorate supraventricular tachycardias in some individuals. The technique involves massaging the area where the common carotid artery bifurcates into its tributaries to the head. Baroreceptors in the region activate the parasympathetic nervous system which can cause a slowing of the heart, reflexive vasodilation and a lowering of blood pressure. Individuals who have had a recent stroke or have more than 70% carotid atherosclerotic plaque are discouraged from using this maneuver.³

Applying ice water to the face and forehead is a safe and effective way to help ameliorate supraventricular tachyarrhythmias in some individuals.  The technique involves immersing the face and forehead in cold water for 5 to 10 seconds then repeating. An alternative technique involves placing a cold cloth on the forehead for a period of time. Again, a reflex parasympathetic response occurs. Cold stimulates the trigeminal nerve in the face and forehead which then stimulates vagal nuclei in the brain causing a slowing AV nodal conduction and a slowing of heart rate.⁴

Intense levels of aerobic exercise can stimulate cardiac arrhythmias in some susceptible individuals. Exercise treadmill testing challenged with pro-arrhythmic isoproterenol infusions showed different mechanisms of myocardial induced arrhythmias. Different mechanisms included the effects of increased sinus heart rate, increased sympathetic tone, and the occurrence of both premature atrial beats and premature ventricular contractions.⁵

Gastro-cardiac syndrome refers to the relationship of the digestive system, primarily the stomach to the heart. It involves a complex interplay of neuro-hormonal, mechanical and physical interrelationships. The vagus nerve is primarily involved and is known to affect both the stomach and heart. A reflexive effect of one organ may affect another organ. Also, the close proximity of the stomach to the heart may involve mechanical and physical effects of one organ influencing the other. In this incidence, a case of dyspepsia caused rhythm disturbances in the heart. Overeating can cause neural and physical effects on heart tissue.⁶

A decrease in blood sugar has a direct anti-arrhythmogenic effect of cardiac tissue and can cause episodes of both bradycardia and tachycardia in vulnerable individuals. The odds ratio of the occurrence of supraventricular tachycardia was statistically significant in individuals with nocturnal hypoglycemia.⁷

Caffeine is one of most commonly consumed drugs in the world. It is found in beverages such as coffee, tea, soda pop, energy drinks, supplements and other foods. Caffeine is a central nervous stimulant that increases catecholamine release thereby inducing tachycardia and increase in blood pressure. Caffeine can also block adenosine receptors A1 and A2 thereby increasing autonomic nervous activity.⁸

Caffeine consumption through coffee, tea, chocolate and other beverages has been purported to increase the incidence of cardiac arrhythmias, both premature atrial contractions (PACs) and premature ventricular contractions (PVCs). In this study, no positive association between caffeine consumption and cardiac arrhythmias was observed in 24-hour Holter monitoring of 1416 individuals and dietary questionnaire. Studies are mixed in terms of the relationship between caffeine consumption and cardiac arrhythmias. Some studies, show a net benefit of decreased cardiovascular mortality with moderate consumption of caffeinated products and other studies show negative outcomes.⁹

A detailed review of the effects of caffeine on atrial and ventricular arrhythmias from studies listed on medical databases, including Medline, Embase and PubMed, revealed conflicting conclusions. Low to moderate consumption of caffeine on the order of less than 300 milligrams per day was not associated with the development of arrhythmias. Several studies showed a beneficial effect and decreased occurrence of heart rhythm irregularities at doses less than this threshold. The authors also cautioned that some individuals might be sensitive to the effects of caffeine on heart rhythm. If a temporal pattern was associated with the consumption of caffeine and the occurrence of heart rhythm disturbances, then limitation or avoidance was suggested.¹⁰

Conflicting studies about the consumption of chocolate and the occurrence of cardiac arrhythmias have occurred. Chocolate contains methylxanthines like caffeine and theobromine which are known cardiac stimulants. Consumption of large amounts of chocolate, in amounts undefined may precipitate tachyarrhythmias in some susceptible individuals. Lower doses of chocolate may have a protective and antioxidant effects.¹¹

Energy drinks with caffeine can stimulate supra-ventricular tachycardia (SVT) in individuals who consume other caffeine-containing beverages like coffee or soda pop. Energy drinks are not benign and can stimulate heart arrythmias in sensitive individuals. Caffeine is a central nervous stimulant and direct sympathomimetic agonist to the SA node of the heart. Caution should be exercised when consuming caffeine-laden drinks.¹²

Acute exposure to alcohol reduces the effective atrial refractory period particularly in cardiac tissue areas near the pulmonary vein. A blood alcohol level of 0.08% equivalent to the consumption of 4 to 6 drinks caused pro-arrhythmogenic changes in atrial tissue. This can lead to atrial-induced cardiac arrhythmias such as atrial fibrillation.¹³

The acute effects of alcohol exposure on heart tissue include a shortening of the refractory period of atrial tissue, slowing in conduction velocity of the electric impulse, increased ectopic atrial activity, and autonomic nervous system imbalance. Chronic exposure to alcohol involves structural and functional remodeling of atrial tissue leading to atrial dilation, elevated pressure and fibrotic scar tissue. Also, chronic alcohol consumption and associated lifestyle factors can lead to obesity, sleep apnea and other sleep disorders and hypertension.¹⁴

“Holiday heart syndrome” was the colloquial term used to describe the occurrence of atrial fibrillation following binge drinking on weekends in individuals who ended up in emergency departments for diagnosis and treatment. Abnormal intracellular calcium release in cardiac tissue causes an intracellular ionic imbalance that activates the sodium and calcium channels to expel calcium and accumulate intracellular sodium. This increases intracellular positive ion accumulation, which leads to cellular depolarization.¹⁵

Ephedrine and pseudoephedrine are common ingredients in over-the-counter (OTC) cough, cold and sinus medications and have been included in energy and weight loss supplements. They are not benign ingredients and can stimulate the sympathetic nervous system and cause tachyarrhythmias like supraventricular tachycardia. An examination of OTC medicines and supplements should be a part of the evaluation of the cause cardiac arrhythmias.¹⁶

Glutamate is an excitatory amino acid found in foods and is also the most common excitatory neurotransmitter in vertebrates. Monosodium glutamate used as a flavor enhancer in foods and condiments can increase glutamate levels in the body. In some sensitive individuals, excess consumption of glutamate can stimulate cardiac tissue and precipitate cardiac tachyarrhythmias like supraventricular tachycardia.¹⁷

Excessive doses of capsicum, the active ingredient in cayenne pepper, has been associated with increased risk of coronary vasospasm, myocardial infarction, and supraventricular tachycardias, including atrial tachycardia and atrial fibrillation. Capsicum can be a direct sympathomimetic cardiac stimulant and can disrupt potassium channels leading to dysrhythmias.¹⁸

Conflicting data has emerged from the use of omega-3 marine lipid extracts and the occurrence of atrial fibrillation. Low doses of marine lipid extracts of less than 1000 milligrams of total DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid) have shown in some studies to reduce the incidence of atrial fibrillation. High doses of marine lipid extracts of greater than 3000 milligrams of the DHA and EPA content have shown in some studies to increase the risk of atrial fibrillation. Additionally, the exact type of oil extract specified such as icosapent ethyl and carboxylic acid formulations may more pro-arrhythmic than other forms of fish oil.¹⁹

Regular consumption of low doses of green tea significantly decreased the incidence of both paroxysmal and persistent atrial fibrillation in this human cohort. Poly-phenolic catechins in green tea with the most abundant being epigallocatechin gallate (EGCG) were believed to decrease inflammation and prevent oxidative damage to the heart muscle. Low dose green tea was deemed as 1 cup per day, while more than 2 cups per day was considered a high dose.²⁰

Plasma electrolyte levels, specifically calcium, magnesium and potassium, were evaluated in 50 patients who experienced supraventricular arrhythmias, including atrial tachycardia and atrial fibrillation. Low levels of both calcium and magnesium were associated with an increased risk of both atrial tachycardia and atrial fibrillation. High levels of potassium were associated with atrial tachycardia and to a lesser degree in atrial fibrillation.²¹

Intravenous magnesium sulphate is effective in relieving cardiac arrhythmias in some patients. Two grams of IV magnesium converted an atrial tachycardia rhythm back to normal sinus rhythm and to a complete resolution of symptoms in a patient where IV adenosine failed to help.²²

Intravenous magnesium sulphate prolongs arterio-ventricular or AV node conduction and the refractory interval and was hypothesized to play a role in paroxysmal supra-ventricular tachycardia. A two-gram dose of magnesium sulphate was given intravenously within 5 minutes. If the arrhythmia did not terminate after 6 minutes, then an additional 2 grams of IV magnesium was given again.²³

Calcium is intimately involved in muscle and nerve contraction, especially cardiac tissue. A case presentation of an individual who presented with supraventricular tachycardia secondary to primary hypoparathyroidism is presented. Calcium levels alter the initiation and duration of the action potential in cardiac muscle and the risk of after depolarization in excitable tissue. Hypocalcemia is associated with both atrial and ventricular arrhythmias.²⁴

Potassium is intimately involved in nerve conduction and muscle contraction, including cardiac tissue. Low levels of potassium increased nervous conduction irritability in heart muscle. Low levels of potassium were diagnosed in three individuals who presented with various supraventricular tachycardias, including atrial tachycardia and atrial fibrillation. Moderately low levels of potassium are typically associated with arrhythmias and T wave abnormalities and mild ST segment depression on EKG readings. Severe hypokalemia can cause life threatening cardiac arrhythmias.²⁵

Saffron (Crocus sativum) supplementation inhibited premature ventricular contractions, ventricular tachycardia and ventricular fibrillation in animal models at high doses. The inhibition of calcium channels was believed to be the mechanism involved in the antiarrhythmic effects of this plant.²⁶

Ginger (Zingiber officinale) supplementation showed inhibition of premature ventricular contractions, ventricular tachycardia and ventricular fibrillation in animal models at high doses. No mechanism of action was given.²⁶

Hawthorn (Crataegus oxyacantha) supplementation inhibited premature ventricular contractions, ventricular tachycardia and ventricular fibrillation in animal models at moderate to high doses. Also, a decrease in ST segment elevation was observed indicating an improvement in myocardial ischemia. Hawthorn was believed to affect myocardial potassium channels.²⁶

Lemon balm (Melissa officinalis) supplementation decreased the incidence of premature ventricular contractions, ventricular tachycardia and ventricular fibrillation in animal models at high doses. Lemon balm also prolonged the PR and QT interval observed on electrocardiogram, similar to class 1 and class 3 anti-arrythmic drugs.²⁶ 

Garlic (Allium sativum) supplementation decrease the incidence of premature ventricular contractions, ventricular tachycardia and ventricular fibrillation in animal models at high doses. Garlic produced a prologation of PR, RR and QT intervals observed on EKG tracings. Garlic was believed to affect myocardial calcium and potassium channels.²⁶

Motherwort (Leonurus cardiaca) supplementation prolonged the PR interval, cycle length and recovery interval in electrocardiogram readings in animal models at low to moderate doses. Motherwort was believed to affect calcium and potassium channels and was shown to prolong the action potential leading to prolonged myocardial contraction.²⁶

Magnolia (Magnolia officinalis) supplementation was shown to decrease the incidence of ventricular tachycardia and ventricular fibrillation in animal models at unspecified doses. Additionally, magnolia reduced myocardial ischemia by increasing endogenous nitric oxide.²⁶

Burdock (Arctium lappa) supplementation decreased premature ventricular contractions, ventricular tachycardia and ventricular fibrillation particularly during periods of myocardial ischemia in animal models at unspecified doses. Burdock was believed to affect potassium and sodium channels. Burdock was also believed to reduce oxidative stress in the myocardium.²⁶

Berberis (Berberis vulgaris) supplementation decreased the incidence of premature ventricular contractions, ventricular tachycardia and ventricular fibrillation in animal models at high doses. Berberis was also shown to prolong the PR, QRS and QT intervals in electrocardiogram readings. Berberis further prolonged the action depolarization potential by affecting calcium and potassium channels. It also prolonged active polarization and shortened the repolarization phase of the myocardium.²⁶

Skullcap (Scutellaria baicalensis) supplementation inhibited atrial flutter and sinus bradycardia in animal models at unspecified doses. No mechanism of action was offered.²⁶

Cinnamon (Cinnamon verum) and other related species supplementation reduced the incidence of premature ventricular contractions, ventricular tachycardia and ventricular fibrillation in animal models at unspecified doses. Cinnamon normalized QT and ST segment changes on electrocardiogram readings. Cinnamon also exerted antioxidative effects on myocardial tissue. It was also believed to affect sodium and calcium channels in heart tissue.²⁶  

Curcumin from turmeric (Curcuma longa) has been deemed a multi-ion channel blocker in cardiac tissue electrophysiology. Supplementation with curcumin displayed anti-arrhythmic effects on heart tissue in animal experimental models. Curcumin preferentially delays sodium channels particularly in late phase action potential depolarization. It also slows calcium and potassium channels activity to some degree.²⁷ 

Bergamot (Citrus bergamia) supplementation helped to reduce the incidence of myocardial arrhythmias in animal models at unspecified doses. Bergamot increased myocardial perfusion during periods of arrythmia-induced ischemia. Bergamot was believed to induce calcium channel blockade and was comparable to Verapamil in effectiveness.²⁶

Sage (Salvia mitorrhiza) supplementation decreased the occurrence of ventricular tachycardia and ventricular fibrillation during periods of ischemia in animal models at unspecified doses. Sage was believed to affect calcium and sodium channels and displayed comparable efficacy as calcium channel blockers like Verapamil.²⁶

Grape (Vitus genus) supplementation in the form of grape juice decreased the number of premature ventricular contractions, ventricular tachycardia and ventricular fibrillation in animal models at moderate doses. Numerous flavonoids found in these plants showed antioxidative activity and an improvement in perfusion during periods of myocardial ischemia. A prolongation of the QT interval was observed. Grapes were also believed to affect calcium and sodium channels.²⁶

Green tea (Camellia sinensis) supplementation in the form of green tea decreased the incidence of both paroxysmal and persistent atrial fibrillation and other arrythmias at low to moderate doses in both animal and human models.  Black tea also showed some anti-arrhythmic activity but also increased the occurrence of premature ventricular contractions. No mechanism of action was given.²⁶

Polyphenols found in a wide range of fruits, vegetables and beverages like green tea, dark berry juice, including blueberry, blackberry and pomegranate juices, were observed to decrease the incidence of ventricular tachycardia, ventricular fibrillation and other arrhythmias in animal and human models at various doses.  Polyphenols like ellagic acid, hesperidin, and resveratrol showed strong anti-arrhythmic effects in animal models. Polyphenols were believed to affect calcium and potassium channels.²⁶

Naturopathic medicine can offer effective strategies to help mitigate the occurrence of cardiac arrhythmias in many cases. The integration of several suggestions can be safe and simple. An example of a practical strategy would involve lifestyle, dietary and nutritional supplementation. Lifestyle factors involve getting proper sleep, exercising moderately, quitting smoking and decreasing stressors. The use of properly instructed Valsalva maneuvers may be beneficial. Dietary changes may involve eating healthier, decreasing sugar and refined carbohydrates, limiting coffee and other caffeine-containing beverages, foods and supplements, adding one or two cups of green tea per day, limiting or completely avoiding alcohol, consuming blueberry, grape or pomegranate juice and avoiding food additives.  Supplementation may include the daily consumption of magnesium and perhaps calcium and potassium when indicated.  Additional recommendations could include the addition of spices like cinnamon, garlic, ginger turmeric or another herbal medicine in food or supplementary form.

As a final concluding remark, it should be stressed that proper evaluation and treatment of cardiac arrhythmias is prudent and tantamount. Naturopathic care should be considered adjunctive support and therapy. While most of the suggestions here are relatively benign their exact interaction with prescription drugs and other allopathic interventions should be evaluated by a licensed medical professional.

References

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Published July 27, 2024