Extrasystole: from diagnosis to therapy

By Cristiano Antonino On Sep 17, 2022

Extrasystole is an often benign alteration of the heart rhythm. It is an early pulsating contraction of the heart, which the affected individual may clearly perceive as an abnormal contraction of the organ, an ‘added beat’ or ‘irregular beat’ compared to the normal heartbeat, but which only instrumental examinations are able to detect and typify with precision

What is extrasystole?

Extrasystole is the most common form of cardiac arrhythmia.

Extrasystoles are indeed extremely common, both in completely healthy people and in patients with an underlying heart disease or other pathological conditions.

But in most cases, this is not a worrying, pathological disorder.

Physiologically, the heartbeat originates from the sinoatrial node, which is located in the upper part of the right atrium, one of the four chambers of the heart, and near the superior vena cava.

This is the ‘electrical control unit’ from which the electrical impulse, which first passes through the atria and then the ventricles, causes the heart to contract, allowing blood to be pumped around the body (systole is the contraction of the heart, while diastole is its relaxation).

In the case of extrasystole, the contraction stimulus does not come from the sinoatrial node but is localised elsewhere (in the atrium, or in the ventricle), thus creating interference with the normal conduction of the electrical impulse: the ectopic impulse bursts at any phase of the cardiac cycle and often alters the duration of ventricular diastole (depending on whether the extrasystole is in an early or late phase of diastole), possibly resulting in reduced cardiac output, especially if the extrasystoles are frequent or repetitive.

Depending on the origin of the stimulus causing the extrasystolic beat, a distinction is made between an atrial extrasystole, when the stimulus comes from the muscles of the atrium, and a ventricular extrasystole, when it comes from the muscles of the ventricle.

What are the symptoms of extrasystole?

These altered pulsations may be ‘blanks’, localised at certain times of the day, or frequent, i.e. always present.

However, the individual with extrasystole does not always feel these abnormal contractions, as the condition is in many cases asymptomatic.

Otherwise, he or she may feel a kind of ‘fluttering’ in the chest at the heart or a kind of ’emptiness’, a stopping of the heartbeat, a fluttering of the heart.

Most extrasystoles are not felt by the patient, especially if they are isolated and occasional.

Symptomatic patients may instead have the sensation of a ‘missing heartbeat’ or a ‘stronger heartbeat’, or feel a kind of ‘fluttering’, a ‘flickering in the middle of the chest’ or a kind of ‘thud’ in the chest at the heart, a ‘hollow’, a ‘dive’ in the heart.

If, on the other hand, the extrasystoles are repetitive (and occur in pairs/triplets, or alternate with the normal rhythm, resulting in a bigeminal or trigeminal rhythm) or are frequent and last for a longer time, the rhythm of the heart is altered and is often felt by the patient with episodes of palpitations that have an accelerated or irregular heartbeat.

In some cases, however, the symptoms become more prominent, especially when associated with prolonged tachycardia: shortness of breath (dyspnoea), increased fatigability (asthenia) and dizziness may appear.

In the case of benign extrasystole, symptoms tend to worsen at rest, sometimes especially after meals or at night, and may disappear with exercise; if, on the other hand, they increase with physical activity, they are often indicative of a more important pathology and require drug therapies or interventions aimed at treating the underlying disease.

This is why a detailed description of the symptoms will be crucial during the arrhythmological examination to define the contours of this arrhythmia.

But beyond the description of symptoms, instrumental examinations are necessary.

Extrasystole: what tests to do for diagnosis?

After a thorough medical examination, the electrocardiogram appears to be the simplest examination, but if the extrasystole is sporadic and unpredictable, the electrocardiogram is unlikely to detect the arrhythmic event or allow a correct diagnosis of its nature and/or extent.

Therefore, the examination most appropriately requested by the cardiologist becomes the dynamic electrocardiogram according to Holter, i.e. the recording of the heartbeat for 24 hours, making it possible to count the number of irregular heartbeats, typify them according to their origin, and assess above all their frequency and repetitiveness in relation to normal heartbeats and their occurrence or reduction according to daily activities (work, meals, sport, relaxation, rest) and the sleep-wake rhythm. Ideally, it would be best to perform a 12-lead Holter 24h ECG as it can accurately identify the origin of the extrasystole.

In the event of further doubts or alterations detected during the examination, a colour Doppler echocardiogram can be requested to better evaluate the cardiac structure and investigate the presence of congenital heart structural pathologies (arrhythmogenic dysplasia of the right ventricle, hypertrophic obstructive cardiomyopathy) or acquired over the years (ischemic or valvular) and the exercise test, which allows the electrical activity of the heart to be recorded while the patient walks on the treadmill or does the exercise bike.

If the extrasystole disappears or diminishes during exercise, it is usually not considered serious.

Conversely, if exercise causes or increases the extrasystolic beats, it is likely that the heart is pathologically fatigued and it will be necessary to pursue further, more in-depth or invasive examinations (cardiac MRI or CT scan, coronarography, myocardial scintigraphy, electrophysiological study).

The role of lifestyle

Extrasystole can occur at any age, thus also in childhood.

But in general, the probability of occurrence increases with age. In a healthy heart, in a young individual with no pathology, extrasystole often correlates with a functional disorder and may be associated with stress (physical and psychological), excessive consumption of smoking, caffeine, alcoholic or carbonated beverages, substances of abuse (cocaine and other narcotics) or certain medications (digoxin, aminophylline, tricyclic antidepressants).

Fever, excessive anxiety or excessive sport can also be triggering factors.

Other times, extrasystolic beats may result from a deficiency of calcium, magnesium and especially potassium in the blood or from an excess of calcium.

Rest, correction of these behaviours or alterations causes the extrasystole to disappear.

Extrasystoles are also very frequent in pregnancy, but are related, as in the case of gastro-oesophageal reflux or an excess of abdominal fat, to vagal or sympathetic reflex stimulation from the abdominal organs.

Such premature systoles should therefore not cause alarm and are not related to heart disease.

In fact, this form of arrhythmia can also occur as a sign of other conditions or pathologies that do not involve the heart, such as thyroid disorders (hyperthyroidism above all, but also hypothyroidism), anaemia, untreated high blood pressure, gastro-oesophageal reflux or other digestive and intestinal disorders such as gallstones, constipation, meteorism.

Finally, however, there are numerous cardiac pathologies that are associated with extrasystole, and arrhythmia is often one of the many symptoms accompanying the underlying pathology: heart failure, a previous myocardial infarction or coronary artery disease in general, valvular heart disease, infection or inflammation of the heart (myocarditis, endocarditis, pericarditis), hypertrophic obstructive heart disease, arrhythmogenic right ventricular dysplasia or pathologies of the cardiac conduction system.

Therefore, an appropriate lifestyle, correction of cardiovascular risk factors, annual control of standard haematochemical examinations and not too intense sporting activity are the ideal prerequisites for a healthy heart and body.

How is extrasystole treated?

Most patients suffering from extrasystole, but otherwise healthy, will not need any therapy, because these are benign phenomena related to non-pathological conditions (anxiety, digestive difficulties, stress, sleep deprivation).

Reducing the most frequent triggers (caffeine, nicotine, drinks, drugs or excessive sport) can certainly be useful and sometimes indispensable in decreasing the frequency or solving the problem, regardless of the symptoms.

In fact, many patients benefit greatly from lifestyle interventions, with a healthy, light diet, regular practice of not excessively intense physical activity, and recovery and maintenance of a healthy weight.

Ventricular extrasystoles

Ventricular extrasystoles are always worth investigating carefully as they may be an indicator of a more important problem.

In some patients, when the symptoms become particularly bothersome and when the extrasystole is very frequent (usually >5000 extrasystoles in 24 hours), either drug therapy or electrical therapy (transcatheter ablation) can be proposed to reduce or even completely terminate the extrasystolic phenomenon.

Transcatheter ablation is a procedure performed under local anaesthesia, with the patient awake or sometimes under general anaesthesia.

Transcatheter ablation of ventricular extrasystole consists of searching for the origin of the extrasystole with a specific catheter that is advanced from a vein (inguinal).

Once the ablation is complete, the patient usually has a fast recovery, within 12 hours he can walk.

Discharge generally takes place 24 hours later.

Atrial extrasystoles

These are always benign but if very frequent, an arrhythmological examination is necessary as they may represent the beginning of atrial fibrillation.

Never underestimate a repetitive atrial extrasystolic phenomenon such as >5000 beats in 24 hours.

A 7-day Holter should be considered: atrial fibrillation must be excluded

In conclusion, in most cases, occasional extrasystoles in non-cardiac subjects do not constitute a health problem, but it is essential to verify their benign nature with the doctor in order to rule out cardiac pathologies or other origins.

Once the diagnosis has been made, and above all once the reduction in arrhythmias under stress has been verified, it is now proven that regular physical activity has a positive effect on reducing extrasystoles and improving both the physical and psychological condition of the non-cardiac individual suffering from extrasystoles.

On the other hand, the presence of heart disease will limit the intensity of physical activity in relation to the type of underlying pathology and its prognosis.

However, even the heart patient is advised to engage in mild regular physical activity, while still respecting his or her overall health condition, and only in limited more severe cases is absolute rest recommended, regardless of the presence of extrasystoles.

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