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Q: I am a 43-year-old woman. I used to have episodes of irregular heartbeat, beating extremely fast. It started when I was 15 and happened maybe once or twice a year into my late 20s. Now, it feels like my heart is changing gears. It beats irregularly for a second or two and then it's normal.

I have also been having pain in my heart. I don't think it's heartburn. It feels like a knife in my heart and I feel it more with each breath. It doesn't last very long. I've gone to the doctor and told them I had pain in my heart. The EKG was normal. I never told the doctor about the irregular heartbeat.

I smoke maybe six cigarettes a day. I know I should quit. Do you think this is from smoking or heart disease or nothing? I feel like a hypochondriac telling all this face to face with a doctor. Thanks for any information.

A: The heart uses four muscular chambers (the left and right atria and the left and right ventricles) to pump the blood through the body.

The pumping action is due to rhythmic contraction of the muscle fibers of the chamber walls triggered by impulses from a rather elaborate electrical system. The actual heart rate is governed by the impulses generated by this system and influenced by the nervous system, as well as hormones and chemicals circulating in the blood stream.

Arrhythmias are abnormalities in the heart's electrical conduction system, causing the heart to beat abnormally slower or faster, or irregularly, with episodes lasting for seconds or years. There are many types of arrhythmias, and they can be minor and without symptoms or lethal.

Each type of arrhythmia has its own cause. Minor arrhythmias can be triggered by excessive alcohol consumption, smoking, stress or exercise. So, yes, your smoking may indeed be contributing to your arrhythmias. Abnormal thyroid function and some drugs can also affect the rate and rhythm of the heart.

However, the most common cause of arrhythmias is heart disease, especially coronary artery disease, abnormal heart valve function or heart failure. Of course, arrhythmias sometimes occur without any detectable cause.

Arrhythmias can be detected based on symptoms or during monitoring. Although the electrocardiogram is the main diagnostic procedure for detecting arrhythmias, it can show heart rhythm tracings over only a short time.

In the case of infrequent episodes of arrhythmia, use of an event recorder, such as a Holter monitor, may be required. Event recorders can record or transmit rhythm tracings for prolonged periods of time.

When life-threatening arrhythmias are suspected, a catheter is inserted in a vein and threaded into the heart. By monitoring electrical stimulation and response, a doctor can identify the cause of the arrhythmia and monitor response to treatment.

There are many more treatments for arrhythmia than there are causes. But arrhythmia without symptoms often requires no treatment at all.

Anti-arrhythmia drugs are used when the episodes cause intolerable symptoms or pose a health risk. No one drug cures all arrhythmias in all people, and it is often necessary to try several drugs at several doses to arrive at a satisfactory treatment.

It may also be necessary to use an implanted pacemaker to override the heart's natural pacemaker.

When the cause of the arrhythmias is known, that cause is treated.

Your arrhythmias and heart pain are suggestive of a number of conditions. You should see a cardiologist for a thorough exam.

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