Otherwise, the physical exam was normal at this time. The most important causes are as follows: Figure 1 shows sinus bradycardia at paper speed 25 mm/s. A doctor may also recommend following a heart-healthy, well-rounded diet, staying active, and managing other underlying conditions. A sinus pause occurs when the sinoatrial node fails to initiate an impulse. may email you for journal alerts and information, but is committed Both parents were deceased; the cause of death for the patient's mother was ischemic stroke and for the patient's father was myocardial infarction. But if you have symptoms of sinus bradycardia, its important to know why. If you have surgery to implant a pacemaker, most people recover within a few weeks. While a physical exam alone is enough to diagnose sinus bradycardia, its only possible with a specific type of test called an electrocardiogram (ECG or EKG). 6. 13. The patient continued receiving electrolyte replacements and small boluses of I.V. Cardiology. The association between a simple measure of QRS voltage and the in-hospital mortality of acutely ill medical patients. For most people, sinus bradycardia doesnt cause any symptoms. Field Summary; static java.lang.String: AAIPacemaker (D.3-PAAAI, SCPECG[1.3], "AAI pacemaker") static java.lang.String . If you notice symptoms, its best to consult with a doctor to determine the cause and begin treatment. Fluid overload in the ICU: evaluation and management. Both sinus bradycardia and sinus arrhythmia may commonly occur during sleep. This is especially true if you have sinus bradycardia because youre in good physical condition and exercise regularly. While sometimes sinus bradycardia doesnt need treatment, other times it can signal serious health conditions that need attention. Fortunately, for people who do need treatment, this condition is often very treatable, and it shouldnt have a big impact on your daily life overall. Sinus arrhythmia. Some people refer to the sinus node as the hearts pacemaker. 16. becoming tired quickly when youre physically active. 4. They can diagnose this condition and determine if its severe enough to need treatment. This is reflected by a QRS complex positive in lead I and negative in leads aVF and II.. In this case, the NP correctly delineated the probable cause for the low voltage warning to be peripheral edema and pleural and pericardial effusions. With that said, it should be noted that ECG is not commonly used to assess fluid volume shifts and electrolyte imbalances. The patient was weak but alert and oriented to person, place, and time. Distribution of cardiac output to the brain across the adult lifespan. Effects of calcium, magnesium, and potassium concentrations on ventricular repolarization in unselected individuals. Keyword Highlighting Highlight selected keywords in the article text. (2022). A slow heart rate for a child can vary depending on their age, Heart rate is a measurement of how many times your heart beats in one minute. The SA node (also known as the sinus node) is your hearts natural pacemaker and generates the electrical current that makes your heart muscle squeeze. Fluid was no longer seen on the X-ray and the echocardiogram showed complete resolution of the pericardial effusion with a normal ejection fraction estimated to be 63%. The QT interval is corrected because it varies depending on the heart rate, so they came up with . Her nutritional intake significantly improved with support from the nutritionist. The electrical signals in the heart are monitored and recorded by an electrocardiogram. A chest X-ray and transthoracic echocardiogram were ordered afterward. The patient had received about 750 mL of the fluid bolus. Low voltage may be present in the following situations: Obesity. The Nurse Practitioner45(9):33-40, September 2020. Low voltage on the ECG is defined as a peak-to-peak QRS amplitude of less than 5 millimeters in the limb leads and/or less than 10 millimeters in the precordial leads. Bradycardia, a slow heart rate, is less than 60 beats per minute for an adult at rest. Sinus bradycardia is less likely to occur in children (but still possible in rare cases) unless it happens because of a condition that a child has when theyre born (congenital). She described the fatigue as extreme exhaustion and debilitating. Her increased fatigue forced her to depend on family and neighbors for help with bathing and grooming, preparing meals, and completing other daily tasks. This clinical case describes how an NP correctly treated a patient with low voltage on an ECG by discerning and managing the underlying causes. Kim DH, Verdino RJ. Vital signs recorded throughout hospital stay. Thus, low voltage requires further follow-up and clinical reasoning is necessary. Dzikowicz DJ, Carey MG. Obesity and hypertension contribute to prolong QRS complex duration among middle-aged adults. 1 There can be little question that, in many instances, low voltage complexes are a result of severe myocardial disease. Sinus bradycardia isnt contagious, meaning you cant pass it from person to person. Once there, they can implant the leadless pacemaker which is about the size of a large multivitamin directly inside the right ventricle of your heart. Borderline means just that, the delay is borderline. When the bradycardia causes hemodynamic symptoms it should be treated. Electrolyte disturbances also cause ECG changes.7,17 This patient presented with hyponatremia, hypokalemia, and hypocalcemia. This is also a normal finding. If you have sinus bradycardia with symptoms, you should see your healthcare provider if your symptoms change noticeably or if your symptoms start to affect your daily life and routine. Kellett J, Opio MO; Kitovu Hospital Study Group. Because sinus bradycardia shares the following symptoms with other more serious heart conditions, you should go to the hospital if you experience: Sinus bradycardia is a condition you may not even know you have, and for most people, it doesnt cause any symptoms. These yearly visits are a key way to detect new problems before they become severe enough to cause symptoms. Sinus Rhythm Possible left atrial enlargement Low QRS voltage in limb leads Cannot rule out anterior infarct, probably old Morphology grossly unchanged Our coder coded as I50.23, I51.7, R94.31. Sometimes an ECG abnormality is a normal variation of a heart's rhythm, which does not affect your health. As a result, the patient was able to make a full recovery and was discharged home. Confusion or memory problems. ECG criteria follows: Regular rhythm with ventricular rate slower than 50 beats per minute. When in doubt whether the bradycardia is physiological, it is useful to perform a Holter ECG (ambulatory recording). The prognostic significance of low QRS voltage (LQRSV) in the electrocardiogram (ECG) of individuals free of cardiovascular disease (CVD) is unclear. Risk of mortality in individuals with low QRS voltage and free of cardiovascular disease. Whats Causing Me to Wake Up with a Racing Heart, and How Do I Treat It? The following are the terms you might see on your ECG report. A result of low voltage on ECG can be due to several causes. 3 things: Sinus bradycardia means the heart rate is less than 60 Low voltage QRS could be associated with many things, including obesity, emphysema, lung disea. This article provides a detailed description of the clinical case and a deeper understanding of the effects of fluid and electrolyte abnormalities on the ECG. Oczkowski SJW, Klotz L, Mazzetti I, et al. Some differential diagnoses from most to least likely included: gastroenteritis, ulcerative colitis relapse, short bowel syndrome, cancer, and chronic fatigue syndrome. 9. At best, may be one can report any symptoms that an individual has to his doctor and get a repeat ECG done after six months to one year. A few other tests may be performed as part of the diagnostic process. Daily weights and input and output measurements were used to closely monitor fluid balance.8. Its sometimes a symptom of certain heart conditions or problems, but it can also be a sign that a person is in very good shape because of regular exercise. Policy. Risk factors for heart disease may include: To diagnose sinus bradycardia, a doctor typically first conducts a physical exam. Chronic obstructive pulmonary disease, or COPD. Such conditions include obesity/epicardial fat, pericardial effusion, pleural effusion, and peripheral edema. daily due to an acute relapse of ulcerative colitis 3 weeks prior to this ED presentation. The speed of correction of fluid overload should be dependent on individual volume status, available treatment options, and an understanding of the underlying pathophysiology responsible for excess fluid.8 Caution is also needed to avoid overly rapid correction of hyponatremia to prevent its complications such as osmotic demyelination syndrome.2 The patient also received a one-time I.V. A case reported is included that describes how an NP correctly treated a patient with low voltage on an ECG by discerning and managing the underlying causes. An abnormal ECG might indicate a variety of conditions. The NP calculated a sodium deficit in hyponatremia of 440 mEq using a desired sodium of 135 mEq/L.2 Stool, urine, and blood cultures were also collected at this time to evaluate for potential infection. 1. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation, mask requirements and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. Sinus bradycardia is a heart rhythm where your heart beats slower than expected (under 60 beats per minute for adults) but otherwise works normally. All rights reserved. Yes, even if your ECG shows up normal, you could have a heart attack. We evaluated the association between LQRSV and all-cause mortality in 6,440 participants (53% women, mean age 60 years) from the Third National Health Many possible factors can cause this to occur. If youre experiencing symptoms consistent with sinus bradycardia, you may want to make an appointment with a doctor. Normal automaticity and pacemaker cells in the heart, Sinus tachycardia & Inappropriate Sinus Tachycardia. She had been battling chronic weight loss and malnutrition due to her ulcerative colitis, which had been flaring up more recently in the last 6 months. It is part of the QRS complex and poor R wave progression can signal a problem. LVH is a result of increased demand put on the LV to increase cardiac output. In all other situations it is necessary to findthe underlyingcauseand direct treatments towards it. This is because ECGs cannot detect an asymptomatic obstruction in your arteries that could put you at risk of a future heart attack. A left anterior fascicular block diagnosis may be benign, but researchers found that people with left anterior fascicular block have a higher risk of congestive heart failure, atrial fibrillation and death. Topics. During this ED presentation, she was still receiving treatment for a recent flare-up beginning 3 weeks prior. solution containing 140 mEq of sodium, 5 mEq potassium, 3 mEq magnesium, 98 mEq chloride, 27 mEq acetate, and 23 mEq gluconate per liter (Plasma-Lyte) to be administered over 1 hour for fluid and electrolyte replacement.3 The I.V. For people who have symptoms, sinus bradycardia is a sign that their body isnt pumping enough blood. The resultant dehydration can be associated with fatigue and muscle cramps and corroborated by hypotension. In those cases, youll need to either take medication daily or have a pacemaker implanted to avoid symptoms and related problems. A healthcare provider, usually your doctor, can diagnose sinus bradycardia using a combination of diagnostic tests and methods. A 12-lead ECG showing low voltage should be a red flag to providers; it can be caused by several serious conditions. Sidhu S, et al. A special group of cells begin the signal to start your heartbeat. Fatigue. Last medically reviewed on January 4, 2023. One of the key steps in interpreting an electrocardiogram (ECG . 422 mS. Leadless pacemakers are implantable using a catheter-based procedure. These diagnoses are considered to be . (See Clinical case study timeline.). Her normal output was 1,500 mL a day. Furosemide 40 mg I.V. You should start feeling better soon after you receive effective treatment for sinus bradycardia (either medications or temporary pacing). The ten ways to improve your heart health infographic. The day before discharge, the patient restarted her home dose of lisinopril. It means your sinus nodes electrical pulse is being properly distributed throughout your heart muscle. Wolters Kluwer Health The NP ordered a comprehensive metabolic panel (CMP) and complete blood count (CBC). Permanent symptomatic bradycardias are treated with artificial pacemakers. and Although it is necessary to correct for fluid and electrolyte deficiencies, poor colloid osmotic pressure due to hypoalbuminemia resulted in deposition of the fluid into the pericardial, pleural, and interstitial spaces leading to pericardial and pleural effusions and peripheral edema.7 Ongoing corticosteroid therapy for the patient's ulcerative colitis may have exacerbated this process, as it is known to cause interstitial edema.7, The NP ordered the I.V. This nerve, which has a direct connection to your brain, is part of your autonomic nervous system. A QTc >470 msec in males or >480 msec in females is abnormal especially if . It is measured using an electrocardiogram (ECG). The Costs of ECG Misdiagnosis due to Poor R-Wave Progression. Learn the symptoms, causes, and treatments for junctional tachycardia, a type of abnormal heart rhythm that starts in the sinus node of your heart. Assessment of Clinical Criteria for. Heres how to check heart rate so you can optimize workouts or identify, Heart disease is a broad term that covers many heart-related problems and conditions, from an abnormal heartbeat and birth defects to a buildup of. What are the Symptoms of Postural Orthostatic Tachycardia Syndrome (POTS)? Borderline ECG Unconfirmed In some people, the heart can still pump blood efficiently with fewer beats per minute. The NP placed the patient on 3 L of oxygen via nasal cannula with positive effect as the oxygen saturation rose to 96% and the respiratory rate decreased to 18 breaths/minute. We do not endorse non-Cleveland Clinic products or services. This can help prevent complications and improve your outlook. Benign causes of sinus bradycardia (SB) do not require treatment. They show how a patients heart is beating in real-time. Chandigarh, World Hemophilia Day is celebrated globally every year on the 17th of April. Dillon J. Dzikowicz is a doctoral candidate at the University of Rochester, School of Nursing, Rochester, N.Y. Significant family history included hypertension and cardiovascular disease in both parents. If you have a pacemaker implanted, you should also see your healthcare provider as recommended so they can make sure your pacemaker is working correctly (healthcare providers can check almost all modern pacemakers using wireless technology, making this part of the visit painless and easy). Ayu Health is a network of high quality hospitals focused on providing high quality healthcare for all. Some error has occurred while processing your request. These tracings are recordings of the rhythm of the heart. The NP believed the low voltage warn-ing and at P and T waves for this patient were due to several factors: electrolyte imbalance, pleural ef-fusion, pericardial effusion, and peripheral edema.7 Lab results Measure Values at ED presentation Values at uid overload Values at . A doctor can help determine which tests may be beneficial for diagnosing the cause of your symptoms and deciding whether or not treatment is necessary. It is also frequently used as the first indicator of a cardiac condition. Though the output was still higher than her usual baseline, there was a documented downward trend and the patient wished to manage it at home. Hence, the treatment for an abnormal ECG depends on the underlying cause.If you need a second opinion on your ECG readings or would like to consult the best cardiologists in Banglore about your symptoms or conditions, reach out to Ayu Health Hospitals. Normal sinus rhythm (NSR) is the rhythm that originates from the sinus node and describes the characteristic rhythm of the healthy human heart. During sinus rhythm, every heartbeat you have starts in the sinoatrial (SA) node, a cluster of electrically active cells near the top of your heart. Although her concerns were raised when developing secondary symptoms associated with the fluid resuscitation, she maintained trust in her medical team. An ECG abnormality can also be a normal variation of the hearts rhythm that has no effect on your health and is no cause for concern. Low voltage is defined as a QRS amplitude of 5 mm (0.5 mV) or less in all of the frontal plane leads and 10 mm (1.0 mV) or less in the precordial leads.7,9 Low voltage can be caused by three main factors: cardiac voltage generation, extracardiac transmission, and equipment-related issues. Whats the Connection Between Estrogen and Osteoporosis? For inpatient stays, unconfirmed diagnoses are indicated using phrases like likely, possible, suspected, or yet to be ruled out or other similar terminology. Learn how estrogen affects bone health and how you can protect yourself from bone loss, Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. An average voltage in the limb leads of < 5 mm with an average of < 10 mm in the chest leads. daily for hypertension, chlorthalidone 12.5 mg P.O. Treating sinus bradycardia can happen in two main ways for people who have symptoms: Medication or devices that use electrical energy to artificially stimulate your heart muscle (commonly known as pacemakers). Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available. It delivers results as a wave pattern. Its a simple, non-invasive test for detecting heart issues and monitoring heart health. infusion was started and the patient was transferred from the ED to the medical-surgical unit. (2022). The stool, urine, and blood cultures returned negative and the patient was not started on antibiotic therapy. The cause of the rise in troponin was most likely related to the acute small pericardial effusion, and not ischemic injury. This is especially true for people whore very physically active and have sinus bradycardia because their hearts are more efficient. Note that patients with chronotropic incompetence may require pacemaker to increase exercise capacity and reduce symptoms. Join our newsletter and get our free ECG Pocket Guide! Learn about the side effects and safety measures. (2015). Compared with a chest X-ray from a previous hospital admission, the chest X-ray showed new findings of pulmonary edema and pleural effusions at the lower bases bilaterally, and the echocardiogram showed a small pericardial effusion with a normal ejection fraction estimated to be 55%. Premature ventricular contractions (PVCs) are extra heartbeats that originate in the bottom of the heart and usually beat sooner than the next expected regular heartbeat. Upon presentation to the medical-surgical unit, she reported new-onset chest pain and shortness of breath. The downward trend of the troponins was promising, suggesting no myocardial harm. Although hyponatremia has no consistent effect on the ECG, hypokalemia and hypocalcemia do have consistent and measurable effects on the ECG. We avoid using tertiary references. A borderline ECG is the term used when there is an element of irregularity in the ECG result. Despite her fatigue, she was an excellent historian and advocate for herself describing her past medical history in detail. To answer that question, several other types of tests are possible. Your message has been successfully sent to your colleague. Bradycardia happens when your heart rate is slower than typical. The ECG showed low voltage, which is an important warning sign requiring careful and methodical evaluation by the clinician to identify the probable cause. Detects unusually, fast, slow or irregular heartbeats, Determines if you are having a heart attack or had a heart attack previously, Patients who seem worried or anxious before the reading show borderline ECG, Improper procedure and/or faulty machines could show borderline readings. In electrocardiography, left axis deviation (LAD) is a condition wherein the mean electrical axis of ventricular contraction of the heart lies in a frontal plane direction between 30 and 90. Claure-Del Granado R, Mehta RL. Case Study from EP Lab Digest. It can also occur during sleep, particularly when youre in a deep sleep. Potential causes of sinus bradycardia can include: Because bradycardia can be caused by damage to the heart, factors associated with heart disease may also be linked to a higher risk of sinus bradycardia. 5. It happens when your hearts pacemaker, the sinus node, generates a heartbeat fewer than 60 times in a minute. 63 mS. QT is the duration of the QT interval . Sinus bradycardia, or a slow heart rate, can be a sign of cardiovascular health in young, healthy adults and endurance athletes. A sinus pause can also occur when the sinoatrial node does initiate an impulse, but the impulse becomes blocked in a way where the atria are prevented from depolarizing. P-waves with constant morphology preceding every QRS complex. In this clinical case, the peripheral edema and pericardial and pleural effusions in addition to the electrolyte imbalances were causes of low voltage on the 12-lead ECG. Based on this clinical reasoning, the NP diagnosed the patient with gastroenteritis and ordered the following interventions: regular diet to encourage nutrition, a nutrition consultation, and a 1,000 mL I.V. A normal sinus rhythm suggests a healthy heartbeat. Please try again soon. Its fairly common, especially in adults over 65 and those who exercise regularly. Specialties. LV strain pattern with ST depression and T-wave inversions in I, aVL and V5-6. Her past medical history included depression, hypertension, past alcohol use disorder, and a 15-year history of ulcerative colitis resulting in the permanent placement of the ileostomy 7 years ago. Usoro AO, Bradford N, Shah AJ, Soliman EZ. If lead placement is verified, the cardiograph is in good-standing, and a similar result is produced, the clinician should consider the result valid and troubleshoot the potential etiology. Sinus bradycardia can also occur along with sinus arrhythmia. At discharge, she was appreciative of the care she received. Many people may not even know their heart rate is under 60 beats per minute unless they have a reason to check their pulse. Diagnostic criteria The QRS has low voltage when: The amplitudes of all the QRS complexes in the limb leads are < 5 mm; or The amplitudes of all the QRS complexes in the precordial leads are < 10 mm There are several etiologies of low voltage: Obesity. But it can also be a sign of an underlying condition requiring medical attention. Interpretation of the low-voltage. Recovery from pacemaker implantation often means limiting your physical activity. However, some infections that can eventually lead to sinus bradycardia such as strep throat are contagious. You may need to wear the device for a few days or sometimes longer. Madias JE. Your heart normally beats between 60 and 100 times per minute. Its usually not serious unless you have symptoms. Sinus Pause. You can learn more about how we ensure our content is accurate and current by reading our. The rate in NSR is generally regular but will vary depending on autonomic inputs into the sinus node. Call us at +91 6366 100 800 for a consultation or book an appointment online. Here are some of the aspects an ECG can help your doctor determine. QT interval prolongation and QRS voltage reduction in patients with liver cirrhosis. Sinus bradycardia can be a sign of a healthy heart. (2015). In this blog, well discuss what it means to have borderline ECG with chest pain, as well as what it means to have an unconfirmed borderline ECG, among other things. The call [], Natural birth control, also known as natural family planning or fertility awareness, involves tracking your [], Sabja seeds, also known as basil seeds or tukmaria, have been touted as a weight [], Pregnancy is a crucial time for a woman to take care of her health and [], Blood donation is an important act of charity that can save lives. Most people with sinus bradycardia dont have symptoms, making this a benign (harmless) condition. For example, healthy young adults or endurance athletes can have sinus bradycardia. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event, (https://www.ncbi.nlm.nih.gov/books/NBK493201/), (https://link.springer.com/article/10.1007%2Fs00399-020-00665-z), (https://accesscardiology-mhmedical-com.ccmain.ohionet.org/content.aspx?sectionid=243369998&bookid=2869#1176522530). 2- An ectopic atrial rhythm is observed in baseline ECG 2A) Baseline Baseline rhythm in an 17-year-old athlete. In adults, the normal QRS axis is considered to be within 30 and 90, right-axis deviation is considered from 90 to 180 1. Benign (physiological) causes of bradycardia (e.g vasovagal reaction, well-trained athletes) need not be treated. Learn the symptoms of postural orthostatic tachycardia syndrome (POTS), including fatigue, weakness, rapid heartbeat, and dizziness when standing. Please try after some time. GE Healthcare. Sinus bradycardia is a type of slowed heart rate that originates from the sinus node of your heart. She appeared malnourished with significant muscle wasting on the temples, deltoids, and clavicles. Although multiple factors may cause low voltage on the ECG, it is important to identify the leading cause and treat appropriately. Further, the patient's pulse dropped to 72 beats/minute. Currently present in They can work with you to diagnose sinus bradycardia and develop a treatment plan, if needed. Sticky patches (electrodes) are placed on the chest and sometimes the arms and legs. Sinus bradycardia can be a short-term problem, especially when it happens because of prescription or recreational drugs or other short-lived circumstances. APRN transition to practice: Program development tips, Privacy Policy (Updated December 15, 2022). Cardiology. The NP performed an assessment that was consistent with fluid overload (edema, crackles in lungs), stopped the ongoing fluid bolus, and transferred the patient to a unit with a higher level of care. Learn how we can help 4.1k views Answered >2 years ago Thank 1 thank A 27-year-old female asked: Sinus bradycardia is a type of slow heartbeat. 17. Topics. Sinus rhythm means your sinus node is setting the tempo for your heartbeat, which is normal and expected. Our website services, content, and products are for informational purposes only. damage that occurs to the heart through things like aging, heart surgery, a congenital condition (present at birth), conditions that cause inflammation around the heart, such as, managing conditions that can contribute to, attending regular checkups with a doctor and letting them know if you experience any new symptoms or changes to existing ones, reaching or maintaining a moderate weight, working with a healthcare professional to manage high blood pressure or high, chest pain that lasts longer than a few minutes. Prominent U waves in V1-3. A 68-year-old female with a chief complaint of increasing fatigue, poor appetite, and increased ileostomy output over the last 2 weeks presented to the ED of a large academic medical center via ambulance. Definitions of Low QRS Voltage: If the total amplitude above and below the isoelectric line is < 5 mm in all 3 standard leads. Her troponins were elevated indicating myocardial injury and were trended to rule out type 2 myocardial infarction. Electrocardiogram voltage discordance: interpretation of low QRS voltage only in the precordial leads. Sinus bradycardia with symptoms happens in about 1 out of every 600 adults over age 65. Interpretation on ekg says 'sinus rhythm, Low Voltage in precordial leads - RSR(V1)-non diagnostic - Horizontal axis for - Answered by a verified Doctor We use cookies to give you the best possible experience on our website. A slower than typical heartbeat (bradycardia) can prevent the brain and other organs from getting enough oxygen, possibly causing these signs and symptoms: Chest pain. But some may require treatment. But it can also be a sign of a failing electrical system. Enter the email address you signed up with and we'll email you a reset link. Electrocardiogram, also known as an ECG or an EKG is a diagnostic tool that is often recommended to people who have a known or suspected heart issue. Is this correct? Patients with tachy-brady syndrome may also necessitate rate controlling drugs (e.g beta-blockers) and anticoagulation (if atrial fibrillation or flutter can be verified). The better your vagus nerve works, the lower your resting heart rate. Last reviewed by a Cleveland Clinic medical professional on 03/07/2022. Dr. Darshan Krishnappa is a Cardiologist with 7 years of experience. 14. Always contact 911 or local emergency services if you experience: Sinus bradycardia is a slow, regular heart rate. Old large MI. This can include things like: They may also take your medical history. heart.org/en/health-topics/arrhythmia/about-arrhythmia/bradycardia--slow-heart-rate, heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascular-disease/coronary-artery-disease, heart.org/en/health-topics/heart-attack/life-after-a-heart-attack/lifestyle-changes-for-heart-attack-prevention, heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/living-with-your-pacemaker, ncbi.nlm.nih.gov/pmc/articles/PMC6028801/, heart.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia, sciencedirect.com/science/article/pii/S1050173819300933, heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/the-ten-ways-to-improve-your-heart-health, heart.org/en/health-topics/arrhythmia/about-arrhythmia, What to Know About Bradycardia (Slow Heart Rate), How to Take Your Pulse (Plus Target Heart Rates to Aim For), Everything You Need to Know About Heart Disease.

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