Magnesium for ectopics and palpitations with Dr Sanjay Gupta

In episode #46, Paul talks with consultant cardiologist Dr Sanjay Guptaon a supplement that he’s found to be beneficial for cardiac patients who experience ectopics and palpitations.

Dr Sanjay Gupta is a Consultant Cardiologist, with specialist ...

And that supplement is Magnesium and in this episode Dr Gupta takes us through what ectopics and palpitations are and why he recommends taking magnesium for them. He talks about the various types of magnesium available and which ones to buy and which ones to avoid.

There’s lots of great help if you are experiencing ectopics or palpitations or just want to know a little more about what goes on in your heart. Another essential listen from this popular YouTube cardiologist.

Available to listen on the link below or Spotify, Apple , Google, YouTube and your favourite podcast player.

#046 Magnesium for ectopics and palpitations with Dr Sanjay Gupta

Paul Swindell: [00:00:10] Hello and welcome to another episode of the life after cardiac arrest podcast with me, your host, Paul Swindell. And today I'm joined by Dr Sanjay Gupta, who is a consultant cardiologist at the York teaching hospital and has a specialist interest in cardiac imaging.

And he has a popular social media presence and can often be seen doing YouTube and Facebook videos on cardiac related matters.

And he's also got a fantastic collection of shirts, which I'm very jealous of actually.

Thank you

He's done a number of videos and all sorts of cardiac issues like palpitations, anxiety, ectopics, AFib, but his most popular one is on magnesium, which has got over one and a half million views on, and that post had 7,000 comments on.

And this is the subject we're going to be talking about today.

So welcome again, Dr Gupta.

Dr Sanjay Gupta: [00:01:05] Thank you for having me Paul.

Paul Swindell: [00:01:07] It's great to speak with you again.

So can you tell me why you did a video on magnesium? Cause it doesn't immediately spring to mind as being a cardiac subject?

Dr Sanjay Gupta: [00:01:17] Yeah. I think it all started because I was interested in talking about heart palpitations. And in particular, one of the commonest, Heart rhythm disorder causing heart palpitations is something called ectopic heartbeats. These are transient extra beats that tend to occur virtually in everyone, but tend to be very much noticed by those people who carry a degree of anxiety.

And when they happen, they can be really, really scary.

The problem well, with these is that, although we recognize them not to be dangerous. They are incredibly scary for patients. When the patient comes to the doctor, the doctor will say, Oh, you've just got a few a topic beads. They're not dangerous. Don't worry about it.

Because the patient can't understand this. He can't understand. He only knows what it feels like. There's very, there was very little support for such patients. You know? No one really talked about ectopics because they were not dangerous. So, in some way they were not important to the medical field because they were not dangerous.

But for patients, and particularly those patients who, who tend to be anxious about their health anyway, it was really something very big, so I felt that I could explain ectopics in a way that made sense to me, and because I did that, I did a video on ectopic heartbeats. A lot of people responded very favourably to that video.

They really felt that I was providing them with information that they hadn't been provided by their own healthcare practitioners. Many of them had been suffering from ectopic beats for 20-30 years. They developed chronic health anxiety as a result.

Really, really terrible stories when you heard them.

As I started doing more videos around ectopic heartbeats, I came across a bunch of people who talked about the fact that magnesium had helped their ectopic heartbeats.

No one had really talked about it on a big scale. These were just anecdotal reports from people who said, well, I took some magnesium and it's really made a big difference. And I thought, well, it'd be interesting to look into this to see whether it really works.

Does it really work?

And do you know?

And if it does, maybe I should talk about it.

I then went and did some reading around the subject and as a doctor, you want to feel like you have some kind of scientific evidence to back up your recommendations.

And I found a very, very small study in Brazil where they used magnesium. They gave magnesium to patients with ectopic heartbeats and they got some really good results and they describe 80 to 90% of patients feeling better.

And although it was a really tiny study and it was in an obscure journal, it gave me enough to be able to feel like I could talk about it.

And I said, well, you know, there is this and here is a study which talked about it. The problem is, the minute you mentioned something like this, people say, well, we want proper studies. We want bigger studies.

Those bigger studies will never be done because magnesium is never going to make money for anyone. And, therefore. Here was something that did have some kind of evidence base. The next step was to try and just recommend it to people, because to my mind, I was confident that it was a safe supplement to use.

So, I thought to myself, well, why dont I talk about it with two people and say, look, there was a small study which suggested it was beneficial. You could try it. It's not dangerous. If suddenly you find that things are better than it's worked for you, and if you don't feel any better then it's maybe not for you.

And on the basis of that video, a lot of people started using magnesium. And I got a ton, a ton of replies, a ton of comments saying, well, you know, when I started taking the magnesium, my palpitations got better. I spoke to my colleagues at work about this and they said, well, how can you recommend this?

There's no really big evidence. And I said to myself, well, do I really need the evidence? Because if the person in front of me who comes to me with a complaint says his problem is better after taking it. Then that's all the evidence I need. We are prescribing this or we are recommending this to improve a person's quality of life, and quality of life is a very individual thing and it has to be measured by that individual's own yardstick.

And so. I started recommending it, and a lot of people responded amazingly to it because they felt, gosh, no one has talked to us about these supplements. when you look, The FDA, the, everywhere. We are chronically depleted of magnesium. This is well-published. It's a well-recognized that three quarters of the population are deficient in magnesium, so it made sense.

When I started recommending it, people said they slept better.

People said that they felt calmer.

People felt that their ectopics got less.

Some people found that their other heart rhythm disturbances, like atrial fibrillation got less anecdotes, that these are not big studies, but how many anecdotes do you need to feel convinced that it's worth trying out?

And that's what's happened with magnesium and me.

Paul Swindell: [00:06:20] Can we just, go over what is exactly a palpitation and what is an ectopic? What is actually going on in our hearts when we, we feel those? I'm I don't think I've ever really had palpitations so much, but after my, cardiac arrest. I was very much aware of what I called missed beats.

Is that what our an ectopic is?

Dr Sanjay Gupta: [00:06:43] The missed beats where you describe a skipping or a fluttering or a miss beat followed by a big thud, those are ectopic beats. So, palpitation is a symptom. Okay. Any time the patient says, my heart feels like it's doing something it shouldn't be doing or it feels odd, that's a palpitation.

Different heart rhythm disturbances can cause palpitations. So, you you may even get palpitation when your heart is not doing anything funny, but it just feels like your heart's doing something funny.

So, for example, if someone comes and scares you, you know, from behind your heart will beat really hard and really fast and that would be a palpitation.

But at that time your heart's not doing anything odd. It's just responding to all the adrenaline that's suddenly been produced in your body. Then you have other heart rhythm disturbances, which may manifest as palpitation, and the commonest by far are ectopic heartbeats. Where what tends to happen there is that your heart will beat and then it relaxes for a certain amount of time.

When it relaxes for a certain, let's say it relaxes for a second and then it beats, so it'll fill up with a seconds worth of blood whilst it's relaxing, and then it will contract and push out that seconds worth of blood. Then it will start relaxing. Now if before it reaches that second of relaxation, let's say after half a second, an extra beat comes in from somewhere.

Then this time. The heart is only pumped out half a seconds worth of blood because the extra beat came in after half a second so it only had half a second. So that will feel like a missed beat. Then to compensate, the normal beat comes in later after one and a half seconds, and now the heart has had to fill up with one and a half seconds worth of blood, which it pumps out, and that then feels like a big thud.

So that's traditionally what ectopics feel like.

They feel like boom, boom, boom, boom, boom.

Paul Swindell: [00:08:35] Yeah.

I've definitely had those.

You said several times that they're not considered dangerous, why is that? Because it sounds like it could be a problem or could it not lead into a, further arrhythmia?

Dr Sanjay Gupta: [00:08:47] Well, we, the reason they're not dangerous usually is because they're non-sustained ectopics by definition, tend to be followed by normal beats.

Paul Swindell: [00:08:59] So what you just get them in isolation.

Dr Sanjay Gupta: [00:09:02] Yeah, definitely. So you'll get that extra beat. And then after a little while you get that big thud, which is the normal beat.

So, because the heart is a pump and when you have an ectopic, any heart rhythm disturbance, means one thing and one thing only. It means that the heart is a pump is not as as efficient. Okay?

So, the efficiency of the heart is compromised during that heart rhythm disturbance.

So, if you've got something which is only going on for a second, followed by normal beats, the inefficiency is non-sustained inefficiency.

It's followed by normal beats, the heart becomes efficient again.

Sustained heart rhythm disturbances are where you get one abnormal beat, followed by another abnormal beat, followed by another abnormal beat for, let's say, you know, 10 minutes there, you've got 10 minutes worth of inefficiency.

So that's why ectopics in general are not dangerous because they represent a non-sustained heart rhythm disturbance as opposed to things like atrial fibrillation, ventricular tachycardia, which are sustained.

Paul Swindell: [00:10:03] I see.

So are ectopics a symptom of an underlying problem, whether that be in the heart muscle or elsewhere in the body?

Dr Sanjay Gupta: [00:10:11] Sure. I mean, I think the first thing to say is that ectopics happen.

So if you take a hundred people off the street and do a 24 hour monitor on them, you will find that on their monitor, 60 out of the hundred, will have some ectopics in a 24 hour period. So they're very, very common. These are people who don't feel a thing.

They're just getting about their own, their lives. Normally they have no symptoms, but if you do a monitor, you'll see some ectopics. So they occur normally. It is true to say that if you have a diseased heart, if you have a structural problem with your heart, let's say you have a cardiomyopathy, let's say you have scar in your heart.

Let's say you have weaker heart, then the heart is more likely to be more irritable and therefore you may get even more ectopics. Significantly more ectopics, and that is why the first thing we do when we have a person who is getting ectopics is to make sure that the heart is structurally normal. We do that by doing an ECG and doing an echocardiogram, a heart scan, and if those are fine, then we turn around and say, we think you have a structurally normal heart.

Therefore, your ectopics are not, a symptom of a diseased heart. The next question then is, if they're not a symptom of a diseased heart, what else could they be?

And the answer is that there was some interesting studies done, the where they took a bunch of people who suffered from health related anxiety and they strapped them to a monitor and they proceeded to make them more anxious.

And as these people got more anxious, they got more ectopics on their monitor. So yes, you know, it's interesting. For example, you mentioned that you know, after, after you were unwell, you got some missed beats. That can simply, of course, it could be due to the fact that if you had a cardiomyopathy or something like that, you may get ectopics as a result of that, but more likely because of the trauma and the stress and anxiety that this whole thing may have caused you.

Paul Swindell: [00:12:05] I see. I see. Yeah, that makes sense. Because, they have dissipated over time and, I've become more relaxed and chilled about what happened as it were.

Dr Sanjay Gupta: [00:12:16] Yeah .

Paul Swindell: [00:12:17] Okay. So, can we look at the actual magnesium?

What is magnesium and why is it important to the body and the heart?

Dr Sanjay Gupta: [00:12:25] Okay, so, magnesium is a essential mineral.

It's a mineral and an electrolyte. It's, I think the fourth most abundant mineral in the body. It's necessary for electrical activity in the heart and the brain. It's a cofactor in more than 300 reactions within the body.

The daily recommended daily allowances, 400 to 420 milligrams for men and 310 to 360 milligrams for women.

But our daily intake is far less than this, most people take between 240 and 370 milligrams at most, and therefore, 75% of the population in the Western world takes in less magnesium than is recommended.

Once we have ingested the magnesium, 30 to 40% is absorbed from our gut and our bowel and some is excreted through our kidneys, but then our kidneys try and reabsorb it when we're deficient.

The other thing to say about magnesium, which is really, really important, is that the blood tests we have for it or not very accurate, and they don't give a true reflection of how much to total body magnesium we have. And that is why a lot of people will come to me and say, well, I've had my magnesium levels checked.

They're okay and I say to them, well, it's still worth trying a magnesium supplement because you can't rely on the blood test. And we are magnesium deficient because we now take in less than we should.

This is because of modern farming methods, which just serve to deplete the magnesium in soil, processing of food depletes magnesium further, we absorb less of it from our stomach because, you know, a lot of patients, for example, are on proton pump inhibitors, for their stomach, and, that reduces acid production and acid is necessary for absorption of magnesium.

And so by far and away, the commonest medication that is prescribed these days are PPIs, Losec, Metrazole, that kind of stuff.

And, they reduce magnesium absorption.

Carbonated beverages, reduce the absorption of magnesium and can make the problem worse.

We're using up a lot more magnesium than we were.

So, things like sugar, a lot more sugar in our foods, and magnesium is required to break the sugar down.

So, we're using a lot more magnesium that way. Stress, sleep disturbance, we'll all get rid of magnesium from the body. And, things like coffee, tea will make us excrete more magnesium in our urine. So, there's loads of reasons why so many of us are deficient in magnesium.

Paul Swindell: [00:14:57] You mentioned about, the food that we eat and the farming methods, depleting the amount of magnesium in our food, but what, what foods should we be looking for?

Because obviously I'll guess food is the best way of getting magnesium into your body, rather than necessarily taking a supplement.

Dr Sanjay Gupta: [00:15:14] I think greens are an important way to get magnesium.

Nuts are an important way to get magnesium in our body, you know, so almonds, spinach, cashew nuts, peanuts.

Trying to eat organically grown foods, whatever, you know, whether you can rely on what is organic or not is another matter, but avoiding processed foods and eating as far as you're aware, organically grown foods from local growers is a good way to get the magnesium into the body, but to my mind, most people benefit from taking a supplement as well.

Paul Swindell: [00:15:46] You mentioned that a blood test is not a good way of telling whether you are deficient is, is there any other way of telling if you're deficient?

Are there any obvious signs?

Dr Sanjay Gupta: [00:15:57] You know, the reality is, it's one of those deficiencies, which isn't reflected in outwardly major, major issues. But, there are some tests that are more accurate, so you can measure something called the red cell magnesium content, but very few places offer that test.

So most places they just do a blood test, and if you go to, you know, local doctors, et cetera, they'll just do the blood test for magnesium, which has no good at all.

I think it's one of those things where the symptoms of a deficiency of very kind of nonspecific, and this is only once you start taking a supplement, if you suddenly find out, gosh, you know, I'm feeling calmer and I'm sleeping better, and a lot of people will say that they get cramps in their legs at night and that they take a magnesium supplement, the cramps go away.

Paul Swindell: [00:16:44] What confused me when I was looking is that there are so many different types of magnesium. are you able to run through sort of some of the main types and the ones that perhaps, heart patients should be looking for in particular?

Dr Sanjay Gupta: [00:16:57] Yeah, there were a lot of different preparations. The common preparation you will come across as something called magnesium oxide and magnesium oxide is is not a good preparation to take because the bioavailability is only 4%.

So, what you take in you only absorb about 4% of what you're taking in, and it has a propensity to cause a loose stomach.

And so, one of the side effects of taking magnesium is loose stool.

So, magnesium oxide is one that I recommend against taking, but there are other preparations like magnesium citrate, magnesium glycinate, magnesium taurate. Any other form of magnesium is fine. You can, you don't actually have to take it orally.

You can take it topically, so you can have oil and rub oil into your skin, and it can be absorbed trans dermally as well.

In my experience, I recommend magnesium citrate or magnesium taurate as a really good supplement for heart palpitations.

Paul Swindell: [00:17:53] Is there any price difference in those products or those types of magnesium?

Dr Sanjay Gupta: [00:17:58] The way it started with me was a lot of people came to me and said, well, can you recommend a preparation?

And the preparation that was studied in the study from Brazil is no longer in production. So, no one seems to be producing that, particular, preparation. So, I decided to recommend magnesium taurate, and a lot of people came back to me and said, you know. That magnesium taurate it's done me a lot of good, I feel better. So, I said, look, that's the one to go for.

Unfortunately, then I discovered that the, company that was making it to raise their prices greatly, and I started recommending magnesium citrate. In the UK we have a health food store called Holland and Barrett, and you can buy magnesium citrate and it's about five or six pounds, something like that.

So, it's not too expensive at all. And, and that seems to work as well as any other preparation.

Paul Swindell: [00:18:48] But what form would that come in, is that a tablet or a powder?

Dr Sanjay Gupta: [00:18:52] I think it's a, I think it's a capsule.

Paul Swindell: [00:18:55] And for people who don't like taking tablets or have got a handful of tablets to take anyway, do you know, are there any other ways to ingest?

Dr Sanjay Gupta: [00:19:03] You can buy magnesium aspartet sachets so that you can mix them in water. And that�s a reasonable way to do it. You can open the capsules and put the powder in and mix it with water and that's another way to do it. Or topical magnesium, magnesium oil.

Paul Swindell: [00:19:21] And what sort of dosage should people will be taking of this? Would it be one size fits all or does it depend on your symptoms?

Dr Sanjay Gupta: [00:19:30] I generally say start with the recommended dose on the tin.

You know, so the preparation you buy, take the recommended dose because we know that at that dose that's going to be safe.

Now, the reality is with magnesium, you know, it has a, you can take a higher doses and not come to harm as opposed to something like potassium, for example.

With potassium, potassium has a very narrow, kind of normal range in the body.

If you go very high, it can be dangerous.

If you go low, it can be very dangerous.

But magnesium has a much wider scope.

So, I normally start off by magnesium citrate, 200 milligrams daily. Magnesium taurate 125 milligrams twice a day.

But any of the preparations, if you take the recommended dose on the box, then that's great place to start.

Paul Swindell: [00:20:23] You mentioned with magnesium oxide that you could get loose stools. Are there any other sort of side effects that you might get from some of the other types of magnesium?

Dr Sanjay Gupta: [00:20:33] I haven't come across any, is the truth. It is just the loose stool that I've come across. Obviously, people who have kidney damage or you know, in those people, you want to be a little bit more careful because they're not treating as well as they should.

But it is mainly the loose stools that have come across as a problem. Having said that, most people tolerate the other forms of magnesium really well. Magnesium glycinate is probably the easiest on the stomach.

Paul Swindell: [00:21:00] As I mentioned earlier, people are probably taking a handful of medications already if they've had a serious heart issue, are there any contra-indictions that it shouldn't be taken with any of these tablets. And should they be going to their, GP or cardiologist before starting on something like this?

Dr Sanjay Gupta: [00:21:21] It's always a good idea for everyone , to get the consent of their, healthcare provider before starting anything. Because everyone's different. And, you know, when I sort of make a recommendation, it's impossible to know the specifics for every person who may be thinking about it.

So, I would always say, you know, there's no harm in trying it. But just make sure that your doctor's happy with you trying it. I have not really found a major contraindication. My patients take all sorts of medications and they can take a magnesium supplement. And I've not really come across anyone, who has suffered, adversely as a result of taking the magnesium.

Some people worry that it has a slight, a very tiny anticoagulant effect. And if you're taking anticoagulants, people worry about that. But again, a lot of my patients do, and they've not come to any harm.

But again, as you know, I would always reiterate that before taking any kind of supplements, make sure your doctor is happy with you doing so.

Paul Swindell: [00:22:19] So have you got anything else to sort of, to sum up

Dr Sanjay Gupta: [00:22:22] Yeah, I think so.

I think the reason I recommend magnesium is for quality of life.

I don't know whether, you know, I don't recommend it because I think, Oh, this will make you live longer, I don't know.

There is no evidence, we don't know, but, I think that try and get out and seeing if your quality of life improves in some way.

And if it does, then that is what you were taking it for.

And if it doesn't, then maybe it's not for you.

But you know as again, you know, if, if for example, you don't sleep well and you start taking a magnesium supplement and you sleep better, well that just is good for you.

It improves your quality of life, it makes you a healthier person.

If you're getting ectopic beats and you take some magnesium supplements and the ectopics get less, well, that's just improved your quality of life.

So, in that sense, I think it's worth trying, and if you feel better, then great.

You know, the problem is very few people are going to go out and say, oh, take magnesium. You know, we are sort of a largely pharma driven industry now.

And, so it is all the, kind of the newest and most expensive medications, and the research and the kind of evidence base that we all crave for, will never, be accumulated for things like magnesium because there's no money.

Paul Swindell: [00:23:41] Okay, my final question would be, if someone starts taking it, how soon would they notice any effect if there is going to be some for them?

Dr Sanjay Gupta: [00:23:50] Usually, you know, within a week or two weeks, a lot of people come back and say, look, that's worked. I definitely think that's helped. So one to two weeks.

Paul Swindell: [00:24:00] And what's the sort of maximum time they should take it for? And if they haven't seen any, effect, and then?

Dr Sanjay Gupta: [00:24:07] Four weeks,

Paul Swindell: [00:24:09] Four weeks.

Dr Sanjay Gupta: [00:24:10] If you've not noticed a benefit in four weeks, and I don't think it's working for you then.

Paul Swindell: [00:24:16] Okay.

That's an absolutely brilliant session on magnesium Dr Gupta, thank you for that. And I'll speak to you next time.

Dr Sanjay Gupta: [00:24:24] Thank you.

If you enjoyed this podcast please do leave a positive review on Apple or other podcast providers as it helps us to spread the word.

Presented and edited by Paul Swindell.

Recorded March 2020. 

Question time #1 with Dr Tom Keeble

In episode #40, in the second part of his conversation with Paul talks with LACA regular consultant cardiologist Dr Tom Keeble.

Dr Keeble answers cardiology questions that have been put to him by members of Sudden Cardiac Arrest UK. These include the subjects of beta-blockers, electrolytes such as potassium and magnesium, atherosclerosis (furring of the arteries) and future risk, anti-platelet therapy, super-asperin, ectopics, ICD’s (implant healing and leads).

Available to listen on the link below or Spotify, Apple , Google, YouTube and your favourite podcast player.

#040 Question Time #1 with Dr Tom Keeble

Paul Swindell: Hello and welcome to another episode of the Life After Cardiac Arrest podcast with me, your host, Paul Swindell. I'm joined today by Dr Tom Keeble, who's here to answer some of your questions that we've had in the group.

So welcome, Tom, and welcome on this beautiful sunny morning.

Dr Tom Keeble: Yeah,

Good morning.

Paul Swindell: We're going to jump straight in because we've already been chatting about Covid 19 but we're going to go onto subjects that aren't related to that cause we tackled most of those questions in the previous episode. So, the first question is, why are beta blockers prescribed after a sudden cardiac arrest that was triggered by an exercise induced oxygen demand ischemia. If the original cause has been rectified by surgery and they had a bypass and they've got ongoing management with statins, diet and exercise. So, it's always the, the beta blocker question

Dr Tom Keeble: So, look. I, a very medically asked question.

So, the bottom line is, beta blockers are a good drug. A lot of patients don't like beta blockers if they have side effects. And I can understand, you know, if you feel tired, if you have bad dreams, if you have, any of the other side effects of dizziness or anything else that you don't like, but the bottom line is, is that had I had a cardiac arrest, whether it's a VF or a VT, a an arrhythmic arrest that needed defibrillation, the best drug on the planet to take is essentially a beta blocker, and the beta blocker is excellent for a variety of reasons. First of all, from the question, the way in which the question was worded,

Number one, it reduces your hearts oxygen demand all of the time because it lowers the heart rate.

Number two, it makes your heart more efficient.

Number three, lowers your blood pressure a bit, which in most patients with cardiovascular disease is what is required.

It also makes the heart pump better. It reduces arrhythmia's, and we know from long term studies, in randomized studies, it prevents cardiovascular death.

So, if you're a patient who's already had essentially an aborted cardiac death from having a cardiac arrest and being resuscitated, it's kind of hard from a medical standpoint, from all of the reasons that I've just stated. Why you wouldn't want to be on a beta blocker.

For me, that would be the tablet that if I wasn't on, I'd be asking, why am I not on it?

Now, as I say, we understand many people may be allergic, people might have terrible asthma and can't take it. That's very rare. and of course. If the side effects are so overwhelming that they outweigh any benefits to you, then of course you wouldn't want to take them.

But most patients tolerate beta blockers well. And I think the other thing is that a lot of the side effects of beta blockers that people would describe are tiredness. Now we know that your group of patients post cardiac arrest and brain injured patients have a huge amount of tiredness and fatigue anyways, it's the number ep symptom that cardiac arrest patients describe, so to put it down to your beta blocker is probably unfair.

So, I think we have to take every patient on a case to case basis. Beta blockers are not good for everybody. That's not what I'm saying, but in the vast majority of cardiovascular induced, and what I mean by that is furred arteries and heart attack induced cardiac arrests. Beta blockers are a good drug and should at least be trialed and should at least be given time to have a chance of getting used to them. But if the side effects are completely untoward and that the patient can not tolerate them, then of course in line with your physician, your cardiologist, they should be considered for a, a different tablet.

Paul Swindell: I mean, there are, there are many different types of beta blocker aren't there?

Dr Tom Keeble: That's true. To be fair, over the last five years, most people have come down to use pretty much one or two, and the most commonly used one, which has a very safe and a good side effect profile is Bisoprolol and the reason why that's good, it's a cardio specific beta blocker, which has particular benefits in heart failure patients, which again, if you've had a cardiac arrest and your heart pump is not completely normal, you will benefit from these cardiac specific ones.

And the ones that we use in those include Bisoprolol, Carvedilol, and Metoprolol. But by far the commonest used one is Bisoprolol. It's generally used once a day you can use it twice a day. I do sometimes, but it's generally used once a day and it's an incredibly good drug.

Paul Swindell: And following on from that, someone says they've got, DCM dilated cardiomyopathy and an SICD, and they've had a couple of, appropriate VF shocks and they've had a couple of, episodes of VF, which have been self-corrected, and they say, is there a link between taking my Bisoprolol at 8pm and my Ramipril and Eplerenone at 10-11 o'clock causing my VF? My heart rate usually sits between 40 to 60 BPM when asleep, but sometimes goes as low as the 30s.

Dr Tom Keeble: Sure. Well, I think it would be very interesting to know just in this personal case, when the cardiac arrests have occurred and the defibrillator has had to do its job, and I think what we do know with any drug is that even if you have a controlled release drug, you do not maintain exactly the same drug concentration over a 24 hour period.

And that we know that there's a sort of bell-shaped curve where you of course, absorb it. It has it sort of peak effect. And then even with slow release medicines, the concentration in your bloodstream, then weans off over the next few hours, then waiting for the next dose the next day, 24 hours later.

And I suppose what this draws into, into close point is that. We need to take our drugs regularly at the same time, at the same, on the same time every day, so that we can give our body the best chance of having a steady state. So, with regards to, to VF and VT. Ramipril and Eplerenone are both drugs to try and improve the heart function and keep the potassium normal.

So, I don't think it's likely that that are sort of a daily variation in their dose would have an effect on whether you would have a VF or VT. But of course, a beta blocker, as we talked about slightly earlier. It's a very powerful protective anti, arrhythmic medicine that if you either missed your dose or maybe you were at a low point in your dose curve and you did some exercise or some stress or something, then that could potentially give rise to it.

If people have a particular arrhythmia at a particular time, let's say at seven o'clock in the morning, the low point of your beta blocker dose because you take it at eight o'clock in the morning then sometimes we space out the beta blocker and give it half in the morning and half at night so that you have a slightly.

Smoother and sort of better profile throughout the 24 hour period. Of course. The other thing is you can consider other anti arrhythmic drugs under the watchful eye of your cardiologist or electrophysiology doctor to ensure you're on the best possible medicines to limit your exposure and limit what your subcutaneous ICD has to do.

Because. At the end of the day, we want the ICD, whether it's subcutaneous or a normal ICD to be your insurance policy, and we don't really want to use, if at all possible, we'd much rather we can control things. With medicines and then the ICD is there just to get you out of jail. If an arrhythmia occurs.

Paul Swindell: you touched on potassium there, someone, so on the third of the question, it's not on potassium. It's talking about magnesium levels and the hearing that magnesium levels are critical to a heart functioning correctly. And it's also read that. Magnesium levels are rarely tested, and they wonder why this is, especially in the cases that are idiopathic.

Dr Tom Keeble: Yeah. Good question. So, I think if any patient comes to the hospital with either cardiac arrest or arrhythmia that has hospitalized someone, that we always measure magnesium. So, magnesium, obviously is in our diet and that's where we predominantly get it from a lot of people are slightly magnesium deficient.

We see that in many patients who come through the door. And the good thing is it's very, very easy to remedy either at home with supplements or what we do in the hospital is we give a magnesium infusion, which we can get the magnesium to normal levels within about two hours. And so that can often help prevent any further arrhythmias.

The other important thing about magnesium is that it also helps reabsorb potassium. So, if you are really low in magnesium, you will often be really low in potassium too, depending on what other drugs you're on and what your dietary intake is like. And so that. Can also cause problems. So often we need to get the magnesium levels back to a normal state, which will then in time allow the potassium levels to come back to a normal level.

And the bottom line is, is that the body is very clever at controlling all of its salt levels and any significant deviation of a particular salt level, be it potassium, bit sodium, be it magnesium bit calcium can have detrimental effects upon your heart rhythm. but no, we definitely don't, monitor magnesium.

And if you like asymptomatic patients in the community that we, we, we've never done that. But if you have persistent arrhythmias, either at home or in hospital, then we would generally, measure it and replace it as we see fit.

Paul Swindell: the question asked about the fact that they are rarely tested it.

I did read somewhere that it's actually hard to do a, an easy test without being invasive, I. E. taking a blood sample or even. Is it in the bone marrow? Is that correct?

Dr Tom Keeble: No. So, it makes, magnesium is definitely from blood serum. You can do it. There is a point of care test. We have it in our catheter lab where you can take a finger prick sample and put it onto, yeah.

Into this point of care machine. And it will give you, you the magnesium, as a point of care. So, it is quite easily measured. You can do it with a, a, say a finger prick or more generally you would do it from a, a blood sample.

Paul Swindell: Do you know the home test kits? Do you know,

Dr Tom Keeble: I wouldn't bother with that to be perfectly Frank.

I think that, you know, I think again, you got to go back to simple things. If you're well and you have a balanced diet, the chances of you having a low magnesium and low potassium are, are low.

Does that make sense?

Paul Swindell: Okay. Yep.

Paul Swindell: and this goes back to the original question. It was sort of a

Paul Swindell: How does having a sudden cardiac arrest due to buildup of cholesterol, increase the risk of a future event if that is being managed.

Dr Tom Keeble: So, if you have a cardiac arrest secondary to a furring up of the arteries or atherosclerosis is the sort of terminology, then usually that is in the setting of a heart attack where you get a sudden occlusion of blood supply to your heart muscle and your heart muscle doesn't like it and goes into this fibrillating state where it sort of wobbles and then you pass out and have your cardiac arrest in the treatment, of course, is CPR recognition and defibrillation, hopefully in the community or if not in the hospital when the paramedics arrive.

What you have to remember with atherosclerosis or furring is it's a continuous process. The risk factors need to be controlled to prevent this from happening long term. So if you get a bypass or a stent, all that really does is sort out the acute problem, gets the blood supply fixed, quickly, but of course if you still have high blood pressure, high cholesterol, overweight, diabetes, and these are all badly controlled, then the furring�s will just come back within a year, six months, two years.

And so, once you've had these events caused by furring, it is absolutely vital that we focus on all of the risk factors to minimize the risks of that happening in the future again. And so really careful attention to cholesterol with statins, really careful attention of blood pressure with pills, really a careful attention of diabetes and weight loss and exercise regimes and all of these things together prevent you from having further events.

The stent is not the cure. All the stent or the bypass does is make the blood supply good at that moment in time. It does nothing to prevent the future events, which of course is the most important thing.

Paul Swindell: Okay. And it's sort of as, as you sort of touched on life lifestyle and diet and things like that, I guess a more and more important, obviously the fewer tablets you can be on, the better.

I would say, personally,

Dr Tom Keeble: I think that's wrong and it's not because I'm a prescribing doctor. I think the bottom line is you need the tablets that you need and everybody will be different. Patient A who's had a idiopathic cardiac arrest and has a defibrillator, may need no tablets or may just have a beta blocker.

It depends completely on the cause.

Depends completely on the risk of other things happening.

Depends completely on the risk factors if there's a coronary patient, but if you've got a patient who has a pump, which is not great, has a high cholesterol, has diabetes. You would, you just need to control all the risk factors.

And I don't mind if that's with tablets or if that's with lifestyle. So let me take diabetes for, for example, if you are a 60 year old male and you have a cardiac arrest because of a heart attack and you are overweight, let's say you're 16 stone and you have type two diabetes, there's really good evidence out there that if you slim down with exercise over time and in a sustainable way.

So say for instance, 12 stone, which may be is the right weight for that human being, then you're type two diabetes is highly likely to go away, I. E. your sugars would go back to a completely normal level because the fat, would you, it gives you insulin resistance and therefore you get type two diabetes.

So, we have to look at evidence too. So, every tablet that a patient is on post heart attack is not just to make us feel better. It's to reduce the risk of cardiovascular death, heart attack and stroke. And for each tablet that patients are on, be that aspirin, be that Ticagrelor, be that an ACE inhibitor, be that a beta blocker.

Be that a statin, be that Eplerenone the list is getting bigger and bigger and bigger. All of them in 20,000 people, randomized controlled trials have shown benefit to prevent heart attack, stroke, and death. And of course, if you are interested in not having a heart attack, stroke, or death again, then we would want to consider taking these tablets unless there's a very good reason not to.

But, I'm very comfortable with people, not taking, tablets. If they can adjust their risk factors with lifestyle modification, which is possible, certainly with diabetes and can be possible with cholesterol, but at the same time, you will not get your cholesterol level to the levels that you really want to, which is less than four.

And not only that, many of these medicines have unexplained benefits. The mechanisms of which we don't understand but are likely to be reduced inflammatory processes, which we know are really important in heart attacks. So my take home message to use, I don't have a disagreement with saying you should be on the minimum number of tablets that you can, you know, that you have to have.

But bear in mind, you need to control each of your risk factors. Well with evidence based medicine. But I think the best one to say, yet, you probably don't need a tablet if you can do it yourself is diabetes. And if you can lose whatever weight is required to get you to your optimum weight, then I think that is a fantastic healthcare way of avoiding diabetes drugs.

But at the same time, you will reduce your cardiovascular risk.

Paul Swindell: Absolutely. No, I wasn't saying that the patient shouldn't be taking tablets or any, evidence based medicines. I'm just saying some people sometimes need to address some easy things like their lifestyle sometimes first

Dr Tom Keeble: it's a part of the equation and you're right. Mental health, physical health and exercise are really important. Joint effort component. I think the other thing is I think we are very lucky in most of the UK that we have a pretty superb, cardiac rehab service certainly in, in Essex we have a brilliant cardiac rehab service and they do a lot of the education surrounding tablets.

And why you're taking this, because. If you find, if patients don't understand why they're taking them, then they often won't take them. Why? Why would you take something that you don't fully understand why you're taking it? But if you're very clear as to what you're taking, why you're taking and what the consequences are of not taking them and what they're trying to achieve, and in collaboration with lifestyle changes, then I think you're much more likely to be successful.

Paul Swindell: Okay. this next question is about someone who's had a auto immune diseases for many, many years and apparently they can lead to heart attacks and cardiac arrest, but without, necessarily any previous risk factors like high blood pressure or high cholesterol

Is there any evidence that supports carrying on the antiplatelet therapy for longer than a year protects the stents, if any, and the heart in general?

So yes, there is emerging evidence, and it's only one tablet. A drug called Ticagrelor. Ticagrelor is super aspirin. So, if you have a stent currently at our cardiac center, you will go home on aspirin and super aspirin, Ticagrelor which is a twice daily preparation at 90 milligrams, generally. Now the, there may be variations, there are two other drugs that we can also use. So. Please don't worry if you're on a different one. This drug was trialed in about 18,000 patients that at the end of that one year, they randomized patients to have a lower dose of Ticagrelor, versus just having aspirin alone.

So, aspirin alone versus a lower dose of super aspirin with the aspirin. And what they wanted to understand is, the problem with the super aspirin drugs that we give with stenting is that they inevitably, when you're trying to prevent clots forming, you inevitably have a downside of potential increased bleeding risk.

And many of your patients who have got these medicines and got stents will describe very much that when they shave, they have bleeding, when they knock themselves in the garden, they have big bruises. Their skin has bruises all of the time on it, and that is the nature of this beast. And so, you can imagine having a super aspirin for longer may be great for your stent, but it may be very bad for bleeding.

You could have a bleed into your tummy, you could have bleeding elsewhere, that requires medical attention. So, this trial was really important to try and understand if. The, the benefits of not running into problems with your stent and your cardiovascular system outweighed any bleeding risk. And the answer was yes.

And so absolutely in low bleeding risk patients. And what I mean by that is genuinely younger patients. You have maybe lots of disease in lots of vessels and potentially diabetes, and there were very specific criteria are likely to benefit from aspirin with a lower dose of super aspirin out to another further three years.

And that certainly what we're currently practicing at the cardiac centre and most places in the UK, because. We follow the same data. but as I said to you, if you are home and you're not on it for longer, then please do not worry. It's because your physician has decided that it's not likely that you're going to benefit.

And the decision is that there is, there were a number of criteria that we need to weigh up, but the predominant one is bleeding risk, and so if you're a high bleeding, which we would never entertain it. In fact, we want to have a short, aspirin and super aspirin, amount of, of time. So it's. The answer is yes, that some people will benefit, but it's on a case by case basis.

There is some evidence for it in certain patient groups. and your cardiologist will support that decision making.

Okay. and this person has got slightly complicated history, although it's actually quite reassuring because he had his, first cardiac arrest back in the, in the nineties or the early part of the 90s, and he had, an IC always had several ICDs, which have saved him.

And back in 2003, he had a, an MV, What's that mitral valve, implanted or, fixed. And he hasn't had a, an incident since then. So, they probably think that that was the original cause of his cardiac arrest. And the fact that he hasn't had one for 17 years now is the possibility of any further arrest now significantly reduced.

Do you think.

Dr Tom Keeble: I think it's incredibly challenging to know. I think the good thing is you rightly say is that this chaps not had one for 17 years. And so that's fantastic news, isn't it? Do you know what I mean, I think none of us have a crystal ball, it's unusual. I mean, there are some associations with mitral valve disease, which can cause cardiac arrest, and arrhythmia's and clearly that has been fixed.

You don't know. Also, at the time of that procedure may be a number of his medicines were also optimized, which may also support his, arrhythmic burden and the fact that he won't have any fear of the trouble with that. So, you know, I think that I, yeah, I, and on a case by case basis, it can be challenging to untangle everything, but it sounds like he's had a great operation to fix his valve and that these tablets are good and he's in good shape.

And I think, yeah, I think to try and untangle it any more than that can be a challenge.

Paul Swindell: Okay.

I've got a couple of questions which are related around ectopic beats, and someone asks, what are the symptoms of ectopic beats and are they anything to be worried about?

Dr Tom Keeble: Every human being on this planet has ectopics. Okay. And what an ectopic beat is, is that the top part of the heart, the atrium beats first, pumps blood into the ventricle, and then the ventricle beats and pumps blood around the body.

And what happens with a ectopic is that the ectopic doesn't have usually, or it can have an atrial beat, but it's usually a ventric ectopic where just an extra beat from the bottom part of the heart comes in. And so often what happens is, is that people feel either an extra beat or a missed beat, and it's incredibly common and people will often have it at times of stress.

People will have more often after they've had tea or coffee. Exercise generally gets rid of ectopic beans. And so look upon it. Topic beats as an extra beat, either from the top or the bottom of your heart. They are generally benign and nothing to worry about.

And what I tend to do in clinic when I see patients that describe these extra beats is do a monitoring usually for 24 hours to understand how many extra beats they have in a 24 hour period. Cause that's important.

If you're having thousands, I. E. you know, that's a lot in a 24 hour period. then we would want to consider trying to use medicine to reduce that amount of ectopics because we know that it can make the heart quite inefficient. But the vast majority of patients do not have that many.

And we'll have, you know, a hundred in a 24 hour period or 30 or so, and actually that is completely normal and is of no concern and we would do nothing about that. We would not advise medications for that. It's only if you have. Literally hundreds or thousands and are bothered by the symptoms. And once again, a beta blocker is an excellent choice of drug to suppress these extra beats, but we would only do that if they are very often and troubling the patient.

Paul Swindell: Okay.

This follow up question, which sort of touches on what you mentioned there, the why are my ectopic beats worse that they, after doing strenuous exercise, and that includes dizziness and tiredness, so they're fine during and immediately after that, the following day is awful.

Dr Tom Keeble: So, with regard to extra beats, the day after exercise, as we talked about, ectopics will usually disappear during exercise.

As the heart rate goes up, the ectopics tend to not occur so frequently usually. It's, I, I can't really explain why a whole 24 hours later you would get more of them. I don't know tha,. I don't know why.

I think if there are concerns and with any sorts of extra beats, we worry about dizziness. So if you have dizziness with that, or have concerns about extra beats, then I would seek advice from your cardiologist who will probably want to do a monitoring or monitor your ICD if you've got an ICD insight to that obviously makes life a lot easier in terms of understanding what's going on from an arrhythmia perspective. but yeah, ectopics in themselves are genuinely self-limiting and not a problem. but of course, you know that we need to tailor treatment to, to individuals from expert cardiologists.

Paul Swindell: Okay.

You touched on ICDs there. I've got a couple of questions on ICDs. I know you're not an ICD, expert, an electrophysiologist, but maybe you, maybe you can answer these.

What sorts of pains do should you expect as your ICD is healing? And what should you be concerned about?

Dr Tom Keeble: Okay, well, I think that, you know, ICD implantation is a surgical procedure, and often they put it underneath the muscle below your, your collarbone.

And so, you know, you can expect that a surgical wound is going to take at least a couple of weeks to heal and to all settle in. There's then the sort of more longer term fibrosis and really getting in a fixed position, which takes then a few more weeks thereafter. And you can imagine. If it is underneath the muscle layer and you're moving your left arm or wherever it is that the arm is closest to it, you can imagine it does take time for that sort of, that healing to happen.

Again, I think ICD patients are incredibly well followed up generally by the implanting centre and you always get a card and the number to call if you've got concerns. I think that, you know. A bit of pain for the first couple of weeks. He's absolutely to be expected, a bit of pain thereafter while it all settled in and fibrosis and gets in a nice happy position long term is to be expected, but I would always discuss it with your, ICD team and at followup, because of course the things we worry about are infection and infection can of course give you pain. So yeah.

Understand how you're feeling in other ways.

Do you have a fever?

Do you feel unwell?

Is it red?

Is it inflamed?

They are really red flag symptoms that I would want you to ring, either your doctor or your ICD team immediately. And normally ICD follow up clinics will see patients the same day if there's genuine concerns about patients. So, I think that a bit of pain is to be expected. I think if that pain is ongoing and more protracted or gets worse, that's the other thing.

Pain from a surgical procedure should get better day on day, week on week. If you noticed that it got completely better and then something new happens and it gets worse, then we would probably want to understand why that is.

We worry about redness.

We worry about infection.

We worry about the wound healing.

And so, they're really important things to, to document and to, to speak to your, team about on the number that you get given when you're discharged home.

Paul Swindell: Okay, cool.

This person was a couple of questions related to, same thing. If, if my defib or the lead is faulty, what can they do about it?

And what is the sort of procedure to rectify it?

And the second part is, is there a certain number of years after which you would not risk the removal of an ICD lead?

Dr Tom Keeble: Yeah. So, so both a good questions.so leads, you have to remember that when you put an lead in an ICD lead or any lead into the heart that's acting as a pacemaker or defibrillator, it moves a lot.

So, it will be fixed at the bottom end in the heart, in the right ventricle usually. And of course, it's fixed at the top, attached to the can and the pacemaker that does the, the pacing. And in between, there's about probably 30, 40 centimeters of lead, and this lead has to obviously be insulated. So, it's got sort of a, a coating around it.

And it also has to, move and be flexible because the hearts are very dynamic organ. And so there are two ways that the leads can become damaged. Number one is they can get fatigued over time. So from all the movement, maybe the lead moves and over five years, the, the sort of movement in the lead cause of the dynamicness of the heart causes little micro fractures in the lead, which then either stop the isolation, the, the, the coating on the outside damages that or damages the lead itself.

And we look at those parameters over time, we know exactly how much voltage is required to deliver a heartbeat to the heart. And so we can measure the impedance of the lead. And if the lead impedance is going up, we know that there may be a fault with the lead over time. So, these things can always be monitored to understand if the lead is fractured or failing.

The second thing, and this was many years ago, very occasionally, we see design fault leads and that there are recalls by companies, to say, you should really take this lead out because we don't think it's going to last. And it's faulty. And obviously that's incredibly disappointing for the company, but more over for the patient and for us as operators.

But at the same time that occasionally happens, but the common is caused is just lead failure because it's, it's run into problems because of fatigue, and as a, it's lost its ability to function properly.

Now, as you can imagine, taking a lead out that may have been in there for a number of years, can be a challenge.

We have two types of leads essentially, we have ones that are called passive fixation, and they look a little bit like an anchor, that you dropped to the bottom of the ocean. And basically you put the lead in with the anchor into the bottom of the right ventricle, and it just kind of fixes into a bit of muscle.

And over time, once it's stuck down, it will get fibrosed and it will be hard to remove. The second type of leads that we use and we're using them more and more currently are called active fixation leads. And these are want of a better term, a screw in lead, and you literally screw it into the muscle where it gets fixed.

Now you can imagine removing a screw in lead may be more straightforward because you may be able to just unscrew it and give it a little tug. And with a bit of luck it will come out. Whereas, of course, the one that has been fixed by sort of anchor technique may be really hard to pull out there. So, extraction of leads a is done by a specialist extraction team in the Essex Cardiac Centre.

We would often do it with cardiac surgery support so that if there are challenges when you pull it out and you cause some damage to the heart muscle, then you have surgical colleagues around to help you to support the patient. And that does occur in a proportion of patients, or you can just leave the lead in.

So very often because the risk of putting a lead out can be, can have significant risks associated with it. You would often just cap it off, is not going to work anymore and put a new lead alongside it that will do the job. and so there are lots of, decisions to be made as to what you do with leads and they will be made by your, your cardiologists at your center.

Paul Swindell: Okay. And, what's the sort of longest time period that, you know, the lead has been extracted?

Dr Tom Keeble: Yeah, I mean, to extract, to lead, often it will be because there's not enough space or there's infection., say often you can leave them just by the side of the other lead and the new one that you put in. I think it's difficult to know that, you know, some leads.

Yeah. The longer the lead has been in, the more difficult it is to remove, usually because it will be stuck down and fibrose. So you also have to have a really good reason to take the lead out and ensure that that's the right thing to do. And most of these decisions will go to a multidisciplinary, electrophysiology team that will decide.

Do you just put another lead in and cap off the old one? Or actually must this old lead come out? And actually, extractions are actually fleetingly rare. We don't do very many in any center in the UK because usually you can leave them be in a benign way and just put a new one next to it.

Paul Swindell: Okay.

Got a question here, which is related around,

Cardiac arrest survivors as general . why do we present such difficulties for other medical disciplines? And she's got one case he's talking about, which is, one of our members who'd had a terrible trouble with his teeth, getting them operated on. By any, anyone, I think he went all around the houses trying to find anyone who is willing to operate them. Are people just scared about how condition?

Dr Tom Keeble: Yeah, I think some of it, I think there's some naivety about your condition. Some of it, it's a bit like just having an ICD alone. A lot of people run to the Hills and don't want to do procedures on people with ICDs, but of course people with ICD still need to have tooth extractions, hip operations and other things just like anybody else.

So, I think, people can be scared because they're worried about a complication of what they do in a high risk individual, if that individual truly is high risk. but I think, as we've said before, you know, yes, cardiac arrest survivors will all have had a cardiac arrest, but in many of them, their risk of future events is modest.

And so, we need to ensure that the cardiac arrest survivors, can get the level of care they require for every type of condition, regardless of their risk.

Paul Swindell: Okay. Yes, absolutely

Paul Swindell: Well, thank you for answering all of those questions, Tom and, it's really great to talk to you again and hopefully some people have got some, anxiety release because of the answers that you've given and I hope to speak to you again soon, so if you need to take care

Dr Tom Keeble: It's an absolute pleasure.

Paul Swindell: Thanks a lot.

This concludes this episode of the Life After Cardiac Arrest podcast and I'd love to know what you think.

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Presented and edited by Paul Swindell.

Recorded April 2020.