I know what you're thinking. This must be an article about the Lord's Prayer or have some spiritual slant. But you're wrong. This is maybe the most important column you will ever read. It may save someone else's life or, more importantly, your own. By the time you finish reading it I expect every one who may be affected by an irregular heart beat (or know someone else who is) to let me know. So get a pen and paper and read on.

My father, whose name was Art, recently passed away at the age of 82. My little nephews and nieces were wondering what happened to him and, as kids do, where exactly he went to. Hence the title above. Is there a heaven? I’m not sure but that is where they think our father Art is. I’ll bet you all have your own opinions. Regardless of what they are we all subliminally hope there is a heaven. We usually tell youngsters that this is where loved ones end up.

Art was an interesting guy. Born in 1915 in our frozen north (I’m Canadian) he was raised with all the usual expectations of immigrant parents. He was preordained a doctor. And so he became one. Struggling against anti-semitism and quotas (common at the time) he graduated at 23, married a 17-year-old small town girl and leapt into the depression era with no money and few prospects. So he started his career as a country doctor. The old time country physicians were called upon any time of day or night to repair battered bodies, deliver babies and even pull teeth. Because people rarely had money in the dust bowl days, Art was remunerated with chickens, guns, vegetables, and in a few other unusual ways. He was given a live owl (I think by a famous old aboriginal chief), a dog that used to raid local chicken coups at night, and he and my mother even had a bathtub full of baby chicks. Like most young men of the time he entered the military and served as a medical officer in a prison camp for what was described as dangerous P.O.W.’s.

Although he did some pioneering work in cardiac surgery (there were no heart-lung bypass machines in those days) the rigors and politics of academia did not agree with him. After being examined for his fellowship by Sir Frederick Banting (the discoverer of Insulin) he pursued general surgery and remained in practice for almost six decades.

Like all human beings even Art would have admitted he was not perfect. Even though we were a large family there were many problems at home, which, for the sake of brevity I will not go into at this point. My father was somewhat cool and distant during troubled times and--like thousands of teenagers who feel (rightly or wrongly) that they lack emotional support--I was out on my own at a fairly young age. One wouldn't consider anyone in our family as close. As my father aged and became ill he seemed to mellow and become somewhat sentimental. Along with this transformation, so too did those of us who suffered come to reconciliation. My brothers, sisters, and I have grown closer. I have never been one to hold a grudge. I feel that life is too short and there are enough tribulations put in our way that one should be forgiving especially with family. When lovers and friends are gone, family is forever.

One of the interesting things about Art was that he was an eternal optimist. When my grandmother was 99 years old and totally debilitated in a nursing home bed, he felt that her life was worthwhile mostly because she was beyond the fear of death. In his latter years Art began walking for fitness. He felt that it would prolong his life. He always kept busy and until his dying days wondered if he should return to medical practice. His patients loved him and relied on him. He was a wonderful grandparent to my nephews and nieces. Although our relationship (and certainly my own personality) was far from perfect and I might have been a different parent than he was, I respected him. I shall miss him. Perhaps our father Art is in heaven.

Strong Heart
Art had a series of strokes. In his terminal coma people always spoke about his strong heart and lungs and that it was sad that the thing that did him in was his greatest strength in life; his mind. Yet I noticed on his cardiac monitor an irregular heart rhythm. Although this problem may run in the family, he was thankfully never aware of it nor did it stop him from walking several miles a day into his eighties.

One of our readers called me describing her experience with an irregular heart rhythm that required emergency intervention and asked me write about it.

Sponge in a Bucket
Every cell in the human heart is a potential pacemaker. Fortunately, only one small area usually takes on that role for a lifetime. As an electric pump we should really consider the heart in terms of a top half that takes blood in, and a bottom half that pumps it out.

The Sinus Node, which is the dominant pacemaker, resides in the top part of the heart. It works on the same principle as a sponge. When you drop a sponge in a bucket it soaks up fluid until it reaches its threshold and can’t take in any more water. A heart’s pacemaker soaks up electrolytes like Sodium and Potassium. When it reaches its threshold it kicks the cell next to it, which repeats the process, sucking up electrolytes and kicking cells in sequence all over the top of the heart. The action causes the atrial chambers to squeeze blood into the bottom half.

Then there is a pause in this sweeping electrical buzz at a gatekeeper area situated between the top and bottom halves of the heart. This pause is designed to allow the lower ventricles time to accept the blood from the top and to fill. After this pause the gatekeeper (the A-V node) then lets the electrical wave carry on down so the bottom half of the heart can start its own electrical domino, effect and pump blood to the rest of the body. The whole process only takes a second.

But why and how does the process repeat itself several times a minute so blood is constantly flowing? Just as you would wring out a sponge to get it back to its original state, the pacemaker (and all the cells that followed the leader) wring themselves out using the energy supplied by oxygen and calories. Then the heart gets ready for its next beat.

Fish out of water
But what happens if the supplier of oxygen and calories to the heart gets clogged, such as in cases of coronary artery disease? Then the dominant pacer may start to falter. And if the other cells in the top of the heart don’t get kicked into action after a few seconds, they may begin to compete for the top job themselves.

Atrial Fibrillation describes a bunch of would-be pacemakers in the top part of the heart discharging irregularly. The heart muscle simply fibrillates and it can neither fill nor empty its chambers properly. It looks like a fish flopping around aimlessly on dry land...it doesn’t get anywhere. Fortunately, gravity allows some of the blood, that gets back to the heart by the action of bodily muscles (via the venous system), to fall into the lower chambers. Because the ventricles are still working, most people survive, but are keenly aware of irregular palpitations in the chest and are often short of breath. The back-up of blood in the system may cause congestive heart failure. In this situation, fluld has nowhere else to go and usually ends up in the lungs or bodily tissues. The skin is often puffy especially in dependent areas like the ankles.

Thanks goodness for the gatekeeper (the A-V node), for it stops most of these chaotic impulses from ever reaching the lower half of the heart. If they were all let through, the whole heart would be a useless mass of rapidly beating jelly. As is, the A-V node only lets through an occasional beat—albeit irregularly—allowing the Ventricles to at least have time to fill and empty properly.

However, if the A-V node gets sick (also from coronary heart disease, scarring, or other problems) it may not be able to hold back the aforementioned flood of electrical activity. This sad scenario is incompatible with life for it now allows ventricular fibrillation to occur, and virtually no blood gets to the body. Ventricular fibrillation can only be stopped by an immediate electrical shock. Defibrillation (the shock paddles seen on all the ER TV dramas) usually stuns the erratic pacemakers into "emptying their sponges" all at once in the hope that a single dominant pacemaker will resume command of a normally beating system.

My heart's all aflutter
Sometimes, if the normal pacemaker is sick, only a few dominant cells (rather than thousands in atrial fibrillation) will compete for the top job. Atrial flutter means that these few cells kick each other repetitively in a rapid sequence. On an Electrocardiogram, the activity has a sawtooth appearance as pacers bounce their messages back and forth in a jousting match which can never be won. However, even though there is a little more regularity than with Fibrillation, this is still a potentially life threatening situation. It all depends on the rapidity of these top chamber rogues. If the impulses are rapid (usually in the neighborhood of 150 impulses a minute) survival once again depends on how many the gatekeeper allows through to the life-sustaining ventricles.

In a hospital, if the doctors feel that the gatekeeper is letting too many impulses through (eg. if the heart is beating more than 150 times per minute) they may try to slow things down. One way is by massaging the neck which causes a reflex slowing in some lucky people. Another way is to give medicine which makes the holes in the electrical sponges smaller so they can’t soak up the electrolytes and saturate as fast. If all else falls, shock treatment is still an option. The shock hurts but patients are usually sedated and given a mild anaesthetic.

Extra beats
As people get older, the millions of sponge-like cells in the heart get aggravated or wear out. Sometimes they get overexcitable and fire on their own without waiting for the master pacemaker to cue them. This can happen in any of the chambers and it results in extra beats called extrasystoles. For many years doctors were very fearful of these extra beats because it was felt that they inevitably caused all the other cells to go crazy, leading to dangerous fibrillation. After all, it is well known that people don’t die from clogging of the arteries (heart attacks); they expire from sudden death cardiac arrhythmias.

Over the past few years doctors have learned that extra beats are more common than they thought. Huge numbers of "normal" asymptomatic volunteers had cardiac monitoring for 24 hours at a time. Scientists found that 60 percent of what they considered the normal ("thin") population have a few extra beats every day. Most people don’t even realize these beats occur. They often feel like a tickle in the throat or chest. Unfortunately, some people are painfully aware of these skips and feel the heart "flip-flopping."

As long as there is no underlying clogging of the arteries or any other serious damage from illness or infection, these beats are usually innocuous. Or so it was thought.

What about us?
Over the past few years I have heard from many large people who experience extra beats, and whose doctors have told them they have nothing to worry about. The problem is that no one has ever surveyed or done proper research on obese subjects. This is worrisome because any advice is anecdotal and pure guesswork. I surveyed some so-called experts who have given me conflicting advice. Some say the hearts of large people have been damaged by fat infiltrating the electrical system (fat cardiomyopathy) causing serious extra beats. Others usually point to sleep apnea as a cause. In a previous article I described apnea as a condition whereby the large thick structures in the neck and throat cause bouts of gasping and snoring during sleep. The resultant lack of oxygen definitely causes extra beats or bouts of very rapid beating in an effort for the body to at least get what little payload is in the system quickiy to where it is needed.

The problem with this seemingly simple explanation of why large people get irregular of fast rhythms, is that even when the apnea is corrected (or when people have lost lots of weight and no longer require sleep apnea machines) the extra beats seem to persist during the day. In this scenario sleep apnea is not the problem. I am not satisfied with all of these explanations.

I am especially perturbed at the usual answer; "tell fat people to lose weight and they will be better off." I know of many large people who lost huge amounts of weight and their irregular heart beats often got worse. It is well known that rapid dieting is deadly and many succumb to sudden death from heart arrhythmias.

The prejudice against large people has negated a proper study of exactly what is going on.

Write me now
There are many more heart beat abnormalities to discuss and I will be pleased to go in to these in greater detail if there is interest. But right now we have a more pressing project to address. If you, or someone you love, is large and/or has irregular skipped or flip-flop heart beats, write to me at Dimensions, Dr. M. Lerner, POB 640, Folsom, CA 95 763-0640. Specifically, tell me the following:

a) the person’s age
b) gender
c) approximate weight
d) how often these irregular beats occur (hourly?, every day?),
e) the circumstances which make them appear or get worse (eg. tense situations, exercise etc.),
f) the time of day they occur,
g) any medication which is prescribed,
h) any other information that you think is important.

Depending on the response I may be able to stimulate the scientific community to pay attention to the millions of large people who deserve the same benefits of medical research as our thinner brethren.

In terms of my father Art? He will be missed. I’m sure he would understand that I’m in no hurry to join him. Heaven can wait. ß

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Heretic Physician