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In clinic I see people who say that they think sometimes their heart skips a beat.

Lots of them.

In fact, it seems to be pretty normal. Most people will start skipping an occasional beat somewhere in their 40s or 50s or 60s. Some people notice and worry about it. When they see me in clinic we discuss three possibililities.

I ask if it feels like the heart is going fast or skipping? And is the skipping regular or irregular? Is it all over the place?

I teach them to take their pulse. Count the number of heartbeats at your wrist or throat in 60 seconds and that is your heart rate. 60 to 100 beats per minute is normal for an adult. If someone is out of shape and runs up the stairs or gets scared by almost getting hit by another driver, they could go up to 120 and still be pretty normal. Faster than 120 is not normal.

If their heart rate is between 60 and 100 and they have an occasional early beat or late beat, those are premature atrial contractions or premature ventricular contractions and it is common. I am not saying that the heart isn't a bit grumpy or that this is a good thing, but it is common. Watch stress, watch caffeine, watch alcohol, stop smoking, exercise, call your mother and father, be kind and generous including to yourself and quit using those illegal drugs like cocaine, heroin and methamphetamines. And oh, stop the Monster Energy Drinks too. Take less pills. You knew that.

If their heart rate is fast, over 120 or uncountable, call an ambulance. Do NOT drive to the emergency room, for two reasons. One is that if it's ventricular fibrillation, your heart could stop and then you could kill yourself and another car full of people. This is bad. Don't do it. The second is that the ambulance crew can run a rhythm strip and catch what it is. Though sometimes they get there and it's gone.

So I had a patient who said she went fast. It did not happen often, so a 24 hour holter was not going to capture it. It did not happen even monthly, so an event monitor might not capture it either. So, I wrote a prescription that said "Tachycardia. Do a stat ECG." As it turned out, she worked in a physician's office. She felt it happen, handed the prescription to a nurse and they got an ECG. Her heart rate was 220. Next thing I hear, the doctor she worked for is admitting her to the ICU and then sending her to the Big City when she is stable. 220 is NOT stable. You can't get blood into those important heart arteries and your body gets very unhappy about this very quickly.

If their heart rate is irregularly irregular, that is atrial fibrillation. Well, sometimes. People can have an early every other beat, which is bigeminy, or an early every third beat, trigeminy. Those feel like a regular pattern. In atrial fibrillation the upper chambers of the heart, the atria, are twitching instead of beating. Doctors call this fibrillating. I have no idea why. I guess twitching isn't impressive enough. Anyhow, the lower chambers of the heart can respond by trying to keep up, so the heart goes too fast. Or by a normal rate or by going too slow.

Once I had a new patient who said his insurance would pay for a "sick" visit but not a physical. He suggested that I do a physical and charge him for a sore throat visit. I asked if his mechanic would charge for an oil change when he did a tune up. He got defensive. I looked at his throat and because I am a thorough type, listened to his heart. Hello, he was in atrial fibrillation. I said, "Sir, you are going to get most of that physical after all and I am admitting you to the hospital." He had no idea he was in atrial fibrillation.

Atrial fibrillation is worrisome for two reasons. One is that since the atria are just twitching, you can form a blood clot. If a piece of the clot breaks off, it can go to your brain and cause a stroke. We don't like this. So there are guidelines for using blood thinners for people who go in and out of atrial fibrillation and for people who stay in atrial fibrillation. Coumadin cuts the stroke risk in half. Aspirin cuts in by a quarter. Coumadin is a pain because you have to do a monthly blood level at a bare minimum and it can get too high so people bleed. However, the good thing about coumadin is that you can instantly reverse it with a vitamin K shot. There are newer blood thinners, one of which has already been yanked off the market for too many bleeds. I am an "old" doctor, 25 years and counting, so I am cynical about new medicines and a slow adopter. Drug reps don't like me.

Atrial fibrillation can also make the heart go too fast. We use either calcium channel blockers, like diltiazem, or beta blockers like atenolol, metoprolol or propranolol, to control the rate. Then the stubborn heart may go too slow, so we use digoxin. We are not supposed to use digoxin if people are over 65, unless "blessed" by a cardiologist. I called one recently because an 85 year old patient has a chronic itchy rash that we think is from diltiazem. The cardiologist said to give him low dose metoprolol. I wanted a back up plan. The cardiologist said that if his blood pressure is tolerating the diltiazem, it will tolerate the metoprolol. Well, maybe, but his stand up blood pressure is 102/60, which is too low really for an 85 year old. The back up, of course, is digoxin, a natural medicine made from foxglove, which I have in my yard. Digoxin also requires blood levels but the advantage is it controls rate and doesn't lower blood pressure. Beyond that lies a pacemaker.

In five years of solo clinic, I have driven three people to the emergency room. All three were in atrial fibrillation. They were all pretty stable, but I did not want them to drive, because they could suddenly not be stable. I offered to call an ambulance for each, but we are less than a mile from the hospital, so I printed out my note and took them myself. That is rural medicine for you.