Extrasystole is an often-benign alteration of the heart rhythm. This is an early pulsation contraction of the heart, which the affected individual can clearly perceive as an abnormal contraction of the organ, an “added” or “irregular” heartbeat compared to the normal heartbeat, but which only instrumental examinations are able to detect and typify accurately. We talk about this topic with Dr. Veronica Barbara Fusi, cardiologist at Humanitas.


What is an extrasystole?

Extrasystole is the most common form of cardiac arrhythmia. Extrasystoles are extremely frequent, both in completely healthy people and in patients with underlying heart disease or other pathological conditions. However, in most cases it is not a worrying and pathological disorder.

Physiologically, the heartbeat originates from the sine-atrial node, present in the upper part of the right atrium, one of the four chambers of the heart, and close to the upper hollow vein. This is the “electrical control unit” from which starts the electrical impulse that, first through the atria and then through the ventricles, makes the heart contract, allowing the blood to be pumped into the body (systole indicates the contraction of the heart, while diastole is its relaxation). In the case of extrasystoles, the stimulus to contraction does not come from the sine-atrial node but is localized elsewhere (atria, ventricles, AV junction), interfering with the normal conduction of the electrical impulse: the ectopic impulse breaks in at any stage of the cardiac cycle and often modifies the duration of the ventricular diastole (depending on whether the extrasystole is inserted in an early or late phase of the diastole), with consequent possible reduction of the cardiac output, especially if the extrasystoles are frequent or repetitive.

According to the origin of the stimulus that causes the extrasystolic beat, an atrial extrasystole is distinguished, in which the stimulus comes from the atrial musculature; a ventricular extrasystole, when it comes from the ventricular musculature; an atrioventricular extrasystole or nodal junctional, with the stimulus coming from the atrioventricular node.


The Symptoms

The altered pulsations can be extemporaneous (so-called “blanks”) or frequent, with a manifestation that follows certain regularity or not. Not always, however, does the individual with extrasystole feel these abnormal contractions, being that the condition is many times asymptomatic. Otherwise, it may feel a sort of “flapping wings” in the chest at the heart level or a sort of “emptiness”, a stop to the heartbeat, a plunge of the heart.

The patient does not feel most extrasystoles, especially if they are isolated and occasional. Symptomatic patients may instead have the sensation of a “missing heartbeat” or a “more intense heartbeat”, or they feel a sort of “flapping wings”, a “flicker in the middle of the chest” or a sort of “thorax thud” in correspondence of the heart, a “void”, a “plunge” of the heart. If, on the other hand, the extrasystoles are repetitive (and occur in pairs/triplets, or alternate with the normal rhythm determining a bi/tri/quadruple rhythm) or are frequent and last longer, the heart rhythm changes and is often felt by the patient with episodes of palpitations that have an accelerated or irregular heart rhythm. In some cases, however, the symptoms become more important, especially if associated with prolonged tachycardia: shortness of breath (dyspnea), increased fatigue (asthenia) and dizziness may appear.

In the case of benign extrasystole, the symptoms tend to worsen at rest, sometimes especially after meals or at night, and may disappear with physical exercise; in the case that they increase with physical activity, they are often indicative of a more important pathology and require pharmacological therapies or interventions aimed at treating the underlying disease. For this reason, a detailed description of the symptoms will be essential during the cardiological examination to define the contours of this arrhythmia. However, beyond the description of the symptomatology, instrumental examinations are necessary.


Diagnostic examinations

What tests are used to diagnose the extrasystole accurately? “Surely, after a careful medical examination and an accurate anamnestic collection, the electrocardiogram is the simplest examination, but if the extrasystole is sporadic and unpredictable, the extemporary electrocardiogram will hardly detect the arrhythmic event or allow to formulate a correct diagnosis of its nature and/or extent. Therefore, the most correct examination required by the cardiologist becomes the dynamic electrocardiogram according to Holter, which is the recording of the heart rate for 24 hours, allowing to count the number of irregular beats, typing them according to their origin, and evaluate especially their frequency and repetitiveness compared to normal heart beats and their appearance or reduction according to daily activities (work, meals, sports, relaxation, rest) and the sleep-wake rhythm,” said Dr. Fusi.

In case of further doubts or alterations detected during the visit, it is possible to request the color doppler echocardiogram to better evaluate the cardiac structure and investigate the presence of congenital type structural pathologies of the heart (right ventricular arrhythmogenic dysplasia, hypertrophic obstructive cardiomyopathy) or acquired over the years (of ischemic or valvular nature) and the stress test that allows to record the electrical activity of the heart while the patient walks on the treadmill or rides a bike.

If the extrasystole disappears or decreases during exercise, it is usually not considered serious. Conversely, if exercise causes or increases extrasystolic heartbeats, it is likely that the heart will be fatigued in a pathological way and it will be necessary to continue with more in-depth or invasive examinations (cardiac MRI/CT, coronarography, myocardial scintigraphy, electrophysiological study).


Lifestyle can also be a factor

Extrasystole can occur at any age, therefore also in pediatric age. But in general the probability of appearance increases with age. In a healthy heart, in a young individual who has no pathology, extrasystole often correlates with a functional disorder and can be associated with stress (physical and mental), excessive consumption of smoke, caffeine, alcoholic or carbonated drinks, substances of abuse (cocaine and other drugs) or some medicines (digoxin, aminophylline, tricyclic antidepressants). Fever, excessive anxiety or excessive sports can also become triggers. At other times, extrasystolic beats can result from a lack of calcium, magnesium and especially potassium in the blood or from an excess of calcium. Rest, the correction of these behaviors or these alterations causes the disappearance of extrasystole.

Even during pregnancy, extrasystoles are very frequent, but are related, as in the case of gastro-esophageal reflux or an excess of abdominal fat, to vagal or sympathetic reflex stimulations coming from the abdominal organs. Such premature systoles must not, therefore, create concern and are not related to heart disease.

The extrasystole form of arrhythmia can also occur as a sign of other conditions or diseases that do not affect the heart, such as thyroid disorders (especially hyperthyroidism, but also hypothyroidism), anemia, untreated arterial hypertension, gastro-esophageal reflux or other digestive and intestinal disorders such as gallstones, constipation, meteorism.

Finally, there are however numerous heart diseases that are associated with extrasystole, and often arrhythmia is one of the many symptoms that accompany the basic pathology: heart failure, myocardial infarction or coronary heart disease in general, valvular heart disease, infections or inflammation of the heart (myocarditis, endocarditis, pericarditis), hypertrophic obstructive heart disease, dysplasia arrhythmia of the right ventricle or diseases of the cardiac conduction system.

Therefore, an appropriate lifestyle, corrections of cardiovascular risk factors, annual monitoring of standard blood tests and not excessively intense sporting activity are ideal prerequisites for a healthy heart and body.


What is the treatment of extrasystole?

“The majority of patients suffering from extrasystole, but otherwise healthy, will not need any therapy, because they are benign and related to non-pathological conditions (anxiety, digestive difficulties, stress, sleep deprivation) – explained the specialist. Reducing the most frequent triggering factors (caffeine, nicotine, drinks, drugs or excessive sports) can certainly be useful and sometimes essential to decrease the frequency or solve the problem, regardless of the symptoms. Many patients benefit greatly from lifestyle interventions, a healthy and light diet, regular physical activity that is not excessively intense, and recovery and maintenance of weight and shape.

In some anxious individuals, or when the symptoms become particularly bothersome, it is possible to use drugs that can slow down the heartbeat: usually we use drugs called beta-blockers, in low doses, or even only anxiolytic drugs, which have proved very effective in reducing the symptoms caused by stress and fear. Relaxation techniques (yoga, pilates, autogenic training) in the mildest forms or anxiolytic/antidepressant drugs and psychotherapy in the most serious forms can also become a solution in reducing the symptoms and frequency of heart rhythm changes.

If, on the other hand, extrasystoles are secondary to non-cardiac diseases, for example in the case of hyperthyroidism, anemia or digestive disorders, the treatment is obviously basic disease. In the presence of heart disease, extrasystole can cause even more serious arrhythmias, so it may be necessary to use antiarrhythmic drugs, beta-blockers, or calcium channel blockers in some cases, or amiodarone in more complex cases.

When it is not possible to achieve a satisfactory result with the drugs, or when it is necessary to treat the underlying heart disease, more invasive interventions are considered (coronarography, valve replacement, radiofrequency ablation, pacemaker implantation).

“In most cases, occasional extrasystoles in non-cardiopathic individuals are not a health problem, but it is essential to check their benign nature with your doctor to exclude heart disease or other causes. Once the diagnosis has been made, and above all the reduction of working arrhythmias has been verified, it has now been demonstrated that the practice of regular physical activity has positive effects on the reduction of extrasystole and on the improvement of both the physical and psychological condition of the non-cardiopathic individual suffering from extrasystole. The presence of heart disease, on the other hand, will limit the intensity of physical activity in relation to the type of pathology underlying it and its prognosis. However, even the cardiac patient is recommended a mild regular physical activity, while respecting his overall health, and only in limited, more serious cases we recommend absolute rest, regardless of the presence of extrasystoles,” concluded the specialist.