ARRHYTHMIAS: KIN 500C - ADVANCED CONCEPTS IN CARDIOVASCULAR PHYSIOLOGY AND REHABILITATION

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500C - Advanced Concepts in Cardiovascular Physiology and Rehabilitation
KIN 500C: ADVANCED CONCEPTS IN CARDIOVASCULAR PHYSIOLOGY AND REHABILITATION
Instructor:	Dr. Darren Warburton
Email:	darren.warburton@ubc.ca
Office:	Lower Mall Research Station
Office Hours:	Via Zoom
Class Schedule:	N/A
Important Course Pages

Acknowledgments

This page was created by Nicholas Burton, Tasha Cory, and Shayan Badiei to meet the requirements of course code, KIN 500C: Advanced Concepts in Cardiovascular Physiology and Rehabilitation. They would like begin by acknowledging that the land on which we gather to complete this project is the traditional, ancestral, and unceded territory of the xwməθkwəy̓əm (Musqueam) People.

Background

Arrhythmias are irregularities in the heart's rhythm caused by disruptions in the electrical impulses that regulate heartbeats (Antzelevitch & Burashnikov, 2011). These disturbances can result in the heart beating too fast (tachycardia), too slow (bradycardia), or irregularly (Antzelevitch & Burashnikov, 2011). Arrhythmias can originate in different parts of the heart, including the atria (supraventricular arrhythmias) or the ventricles (ventricular arrhythmias) (Kingma et al., 2023). While some arrhythmias are benign and may not cause noticeable symptoms, others can lead to serious complications such as stroke, heart failure, or sudden cardiac arrest (Kingma et al., 2023).

The heart's electrical system relies on the sinoatrial (SA) node, known as the natural pacemaker, to generate electrical impulses that travel through the atrioventricular (AV) node and into the ventricles (Antzelevitch & Burashnikov, 2011). Any disruption in this conduction system can lead to abnormal rhythms. Arrhythmias can be triggered by various factors, including structural heart disease, electrolyte imbalances, ischemia, genetic predisposition, and external influences such as medications or stimulants like caffeine and alcohol (Antzelevitch & Burashnikov, 2011; Kingma et al., 2023).

The clinical significance of an arrhythmia depends on factors such as its duration, frequency, and impact on cardiac output (Kingma et al., 2023). Some arrhythmias, like premature atrial contractions (PACs) or premature ventricular contractions (PVCs), are common and typically non-life threatening (Loffler & Darby, 2020). However, others, such as atrial fibrillation (AF) or ventricular fibrillation (VF), require medical attention due to their association with life-threatening complications (Kingma et al., 2023). Treatment options range from lifestyle modifications and medications to advanced interventions like catheter ablation, pacemakers, or implantable cardioverter-defibrillators (ICDs) (Nagpal et al., 2024).

Measurement of Arrhythmias

Example of ECG/EKG Recording with 12 LeadsImage by Jmarchn, licensed under CC BY-SA 3.0 via Wikimedia Commons.

The measurement and diagnosis of arrhythmias primarily rely on electrocardiography (ECG or EKG), which records the heart's electrical activity (Katal et al., 2023). A standard 12-lead ECG provides a snapshot of cardiac rhythms and helps identify abnormalities in impulse generation and conduction (Park et al., 2022). Continuous monitoring methods, such as Holter monitors and event recorders, are used for detecting intermittent arrhythmias that may not be captured during a short ECG recording (Carrington et al., 2022).

More advanced diagnostic tools include implantable loop recorders (ILRs), which are small devices implanted under the skin to monitor heart rhythms over extended periods. These are particularly useful for detecting arrhythmias that cause unexplained syncope (fainting) or infrequent palpitations (Bisignani et al., 2018). Wearable devices, including smartwatches with ECG capabilities, are emerging as accessible tools for detecting conditions like atrial fibrillation (Carrington et al., 2022).

In clinical settings, electrophysiological (EP) studies may be conducted to map the electrical pathways of the heart and pinpoint the source of arrhythmias. This invasive procedure involves threading catheters with electrodes into the heart via blood vessels, allowing physicians to evaluate conduction abnormalities and determine appropriate treatment strategies (Hilfiker et al., 2015). Together, these measurement techniques enable accurate diagnosis and guide personalized management of arrhythmias.

Electrocardiography (ECG/EKG)

Electrocardiography (ECG or EKG) is the primary tool used to measure and diagnose arrhythmias (Hoefman et al., 2011). A standard 12-lead ECG records the heart's electrical activity from multiple angles, providing a detailed assessment of rhythm abnormalities. It is particularly useful for detecting atrial and ventricular arrhythmias, conduction blocks, and ischemic changes. However, since arrhythmias can be transient, a single ECG recording may not always capture intermittent abnormalities, necessitating longer monitoring periods (Carrington et al., 2022).

Holter Monitors and Ambulatory ECG

Example of Holter Monitor Set Up Image by National Heart Lung and Blood Institute (NIH), showing how a Holter or event monitor attaches to a patient and displays an electrocardiogram strip. Public domain. Retrieved from Wikimedia Commons.

For patients experiencing occasional arrhythmias, ambulatory ECG monitoring devices like Holter monitors are commonly used (Hoefman et al., 2011). A Holter monitor is a portable ECG device that records continuous heart activity over 24 to 48 hours, or even up to several weeks in some cases (Hoefman et al., 2011). These devices are particularly useful for detecting arrhythmias that may not occur during a brief in-office ECG (Carrington et al., 2022). Ambulatory event monitors, another variation, allow patients to activate the recording when they experience symptoms, providing targeted data collection.

Implantable Loop Recorders (ILRs)

For long-term arrhythmia detection, implantable loop recorders (ILRs) are used (Nordgaard & Melchior, 2021). These small devices are implanted under the skin and continuously monitor heart rhythms for months to years. ILRs are particularly valuable for diagnosing unexplained syncope (fainting), detecting silent atrial fibrillation, and identifying rare but serious arrhythmias that may not be caught by shorter-term monitoring (Bisignani et al., 2018). Data from ILRs can be transmitted wirelessly to healthcare providers for real-time assessment.

Wearable and Consumer Devices

Recent advancements in wearable technology have introduced consumer devices capable of detecting arrhythmias, such as smartwatches with ECG capabilities (Hoang-Vu Tran et al., 2023). These devices, while not as precise as medical-grade ECGs, can provide early detection of atrial fibrillation and other rhythm abnormalities, prompting individuals to seek further medical evaluation (Hoang-Vu Tran et al., 2023. Some wearable patches, like the Zio Patch, offer continuous ECG monitoring for up to two weeks, providing a convenient alternative to traditional Holter monitors (Fung et al., 2015).

Electrophysiology (EP) Studies

For a more detailed and invasive assessment, electrophysiology (EP) studies are performed in specialized cardiac labs. During an EP study, catheters with electrodes are inserted into the heart through blood vessels to map electrical activity and identify abnormal conduction pathways (Hifiker et al., 2015). This technique is particularly useful for evaluating complex arrhythmias, determining the risk of sudden cardiac death, and guiding catheter ablation therapy for conditions like supraventricular tachycardia (SVT) and ventricular tachycardia (VT) (Hifiker et al., 2015).

Each of these measurement techniques plays a crucial role in diagnosing and managing arrhythmias, with the choice of method depending on the suspected arrhythmia type, symptom frequency, and patient risk factors.

Classifications of Arrhythmias

Arrhythmias, or irregular heart rhythms, are classified based on their origin within the heart, as well as the nature of the rhythm disturbances (Antzelevitch & Burashnikov, 2011). These classifications help in understanding the mechanisms, diagnosing the condition, and determining appropriate treatments.

1. By Origin

• Supraventricular Arrhythmias: These arrhythmias originate above the ventricles, typically in the atria or the atrioventricular (AV) node. They include conditions such as atrial fibrillation, atrial flutter, and supraventricular tachycardia (SVT) (Kotadia et al., 2020). Supraventricular arrhythmias often involve abnormal electrical activity that disrupts the coordinated contraction of the atria, which can affect heart rate and efficiency (Kotadia et al., 2020).
• Ventricular Arrhythmias: These arrhythmias arise from the ventricles and include conditions such as ventricular tachycardia, ventricular fibrillation, and premature ventricular contractions (PVCs) (Bhaskaran et al., 2022). Ventricular arrhythmias can be life-threatening due to the potential for causing inadequate blood flow and leading to sudden cardiac arrest (Bhaskaran et al., 2022).

2. By Rhythm and Conduction

• Tachyarrhythmias: These are fast heart rhythms with a rate exceeding 100 beats per minute (bpm) (Trappe, 2010). Tachyarrhythmias can be either supraventricular or ventricular in origin and include conditions such as atrial fibrillation (AF), atrial flutter, and ventricular tachycardia (Trappe, 2010).
• Bradyarrhythmias: These are slow heart rhythms with a rate less than 60 bpm (Trappe, 2010). Bradyarrhythmias may arise from disturbances in the sinoatrial (SA) node or other conduction pathways, leading to conditions like sinus bradycardia, heart block, or sick sinus syndrome. In extreme cases, bradyarrhythmias can lead to syncope or reduced cardiac output (Trappe, 2010).

3. By Mechanism

• Reentrant Arrhythmias: These occur when an electrical impulse repeatedly travels through a part of the heart, re-entering previously excited tissue and causing a loop (Antzelevitch & Burashnikov, 2011). This mechanism is responsible for many types of arrhythmias, such as atrial fibrillation, atrial flutter, and certain types of ventricular tachycardia (Antzelevitch & Burashnikov, 2011).
• Focal Arrhythmias: Focal arrhythmias are caused by ectopic pacemaker activity from a localized area of the heart, rather than the normal sinoatrial node (Antzelevitch & Burashnikov, 2011). These arrhythmias include conditions like atrial or ventricular premature beats and ectopic atrial tachycardia (Antzelevitch & Burashnikov, 2011).
• Conduction Disorders: These involve abnormal conduction of electrical impulses through the heart, often due to damage to the heart's conduction system (Antzelevitch & Burashnikov, 2011). Examples include atrioventricular (AV) block and bundle branch blocks, where the electrical signal is delayed or blocked between the atria and ventricles (Antzelevitch & Burashnikov, 2011).

4. By Duration

• Acute Arrhythmias: These are sudden-onset arrhythmias that can occur as a result of myocardial ischemia, electrolyte disturbances, or other acute cardiac conditions. They often require immediate medical intervention to prevent further complications.
• Chronic Arrhythmias: Chronic arrhythmias persist over time and may require ongoing management. Atrial fibrillation is an example of a chronic arrhythmia that can lead to significant health issues, such as stroke or heart failure, if not properly controlled.

5. By Severity

• Life-Threatening Arrhythmias: These include arrhythmias that can lead to severe consequences, including sudden cardiac arrest (Kingma et al., 2023). Examples are ventricular fibrillation and certain types of ventricular tachycardia.
• Non-Life-Threatening Arrhythmias: These arrhythmias may cause symptoms such as palpitations or dizziness but do not immediately threaten life (Kingma et al., 2023). Many supraventricular arrhythmias, such as benign atrial premature beats, fall into this category.

Common Types of Arrhythmias

Arrhythmias can be classified into different categories based on their origin, heart rate effects, and underlying mechanisms (Antzelevitch & Burashnikov, 2011). They may arise from the atria (supraventricular arrhythmias) or the ventricles (ventricular arrhythmias) and can cause the heart to beat too fast (tachycardia), too slow (bradycardia), or irregularly (Antzelevitch & Burashnikov, 2011). Some arrhythmias, such as atrial fibrillation, are common and may increase the risk of stroke, while others, like ventricular fibrillation, are life-threatening and require immediate intervention (Elsheikh et al., 2024).

The classification of arrhythmias is important for determining the appropriate diagnosis and treatment. While some irregular heart rhythms cause noticeable symptoms such as palpitations, dizziness, or fainting, others may be asymptomatic and only detected through medical testing (Nagpal et al., 2024)). Various factors, including structural heart disease, electrolyte imbalances, medication side effects, and genetic predisposition, can contribute to arrhythmia development (Antzelevitch & Burashnikov, 2011).

The following table provides an overview of the different common types of arrhythmias, their characteristics, and their clinical significance:

Arrhythmia	Clinical Description	ECG Characteristics	Clinical Presentation
Atrial Fibrillation	Irregular and often rapid heart rate originating from the atria, causing the atria to fibrillate rather than contract normally	No distinct P waves, irregularly irregular rhythm, rapid ventricular response	Palpitations, fatigue, dizziness, shortness of breath, risk of stroke
Ventricular Fibrillation	Ventricles quiver ineffectively, preventing blood from being pumped to the body	Chaotic, disorganized electrical activity, no identifiable QRS complexes, or P waves	Sudden collapse, no pulse, unresponsiveness, requires immediate defibrillation
Atrial Flutter	A rapid but regular atrial rhythm, often occurring due to a reentrant circuit in the right atrium	Sawtooth-shaped flutter waves, especially seen in lead II, regular ventricular rhythm	Palpitations, dizziness, fatigue, shortness of breath, risk of stroke
Supra-ventricular Tachycardia (SVT)	A general term for any arrhythmia that originates above the ventricles, usually characterized by a rapid heart rate	Regular, narrow QRS complexes, rapid heart rate (usually 150-250 bpm), absent or abnormal P waves	Palpitations, dizziness, lightheadedness, shortness of breath, chest pain
Ventricular Tachycardia	A fast heart rate originating from the ventricles, which can lead to hemodynamic instability or sudden cardiac arrest if untreated	Wide, bizarre QRS complexes, usually greater than 120 ms, often with a regular rhythm	Palpitations, dizziness, syncope, chest pain, lightheadedness, may lead to sudden cardiac arrest
Idiopathic Ventricular Rhythm	A rhythm originating from the ventricles without an underlying structural heart disease or known cause	Wide QRS complexes, but no clear cause identified	Often asymptomatic but may present with palpitations or dizziness
Sinus Arrhythmia	A normal variation in heart rate related to breathing (heart rate increases during inspiration and decreases during expiration)	Regular rhythm but varying P-P intervals with a normal sinus rhythm	Generally asymptomatic; no clinical concern in healthy individuals
1st Degree AV Block	A delay in the conduction of the electrical impulse from the atria to the ventricles	Prolonged PR interval (> 300 ms) but every P wave is followed by a QRS complex	Usually asymptomatic, may cause mild fatigue or dizziness if the block is severe
2nd Degree AV Block - Mobitz Type I	A progressive delay in conduction at the AV node leading to intermittent non-conducted P waves (dropped beats)	Progressive lengthening of the PR interval until one P wave is not followed by a QRS complex (dropped beat)	Often asymptomatic, but may cause dizziness or syncope in severe cases
2nd Degree AV Block - Mobitz Type II	A more serious form of 2nd degree block with intermittent non-conducted P waves, but without the progressive PR interval elongation seen in type I	Dropped beats (non-conducted P waves) without preceding PR interval elongation	May cause dizziness, syncope, or even sudden cardiac arrest in severe cases. Often requires a pacemaker
3rd Degree AV Block - Complete Heart Block	Complete failure of electrical communication between the atria and ventricles, causing atria and ventricles to beat independently	P waves and QRS complexes occur independently at different rates (atria and ventricles), with no relationship between them	Syncope, fatigue, dizziness, chest pain, and risk of sudden cardiac death
Right Bundle Branch Block	A delay or blockage in the electrical conduction through the right bundle branch, causing delayed right ventricular activation	Wide QRS complex (> 120 ms), an rSR’ pattern in V1, and a broad S wave in lead I and V6	Generally asymptomatic but may cause mild fatigue or dizziness
Left Bundle Branch Block	A delay or blockage in the electrical conduction through the left bundle branch, causing delayed left ventricular activation	Wide QRS complex (> 120 ms), broad and notched R wave in lead I and V6, deep S wave in V1	May cause fatigue, shortness of breath, or chest pain, especially in those with underlying heart disease
Right Ventricular Hypertrophy	Thickening of the right ventricular wall due to increased workload, often secondary to pulmonary disease or left heart failure	Right axis deviation, tall R waves in V1, deep S waves in V5/V6	Shortness of breath, fatigue, palpitations, or swelling in the legs
Left Ventricular Hypertrophy	Thickening of the left ventricular wall, often due to hypertension or aortic stenosis	Increased voltage of the QRS complexes, deep S waves in V1, and tall R waves in V5 or V6	Fatigue, shortness of breath, chest pain, or palpitations
Right Atrial Enlargement	Enlargement of one or both atria, usually due to chronic pressure or volume overload	Tall, peaked P waves (P pulmonale)	Fatigue, palpitations, shortness of breath, or symptoms of heart failure
Left Atrial Enlargement	Enlargement of one or both atria, usually due to chronic pressure or volume overload	Broad, notched P waves (P mitrale)	Fatigue, palpitations, shortness of breath, or symptoms of heart failure
Wolff Parkinson-White Disease	A congenital condition where an accessory pathway between the atria and ventricles causes a pre-excitation of the ventricles	Shortened PR interval, presence of a delta wave (slurred upstroke of the QRS complex), and a wide QRS complex	Palpitations, dizziness, syncope, risk of SVT or sudden cardiac arrest

Note: Adapted from Electrocardiography and Cardiovascular Disease by Dr. B. Morrison, 2025, lecture slides, KIN 500C, University of British Columbia.

Causes and Risk Factors to Arrhythmias in the General Canadian Population

Introduction

In Canada, arrhythmias are a growing public health concern due to an aging population, increased prevalence of chronic diseases, and rising cardiovascular risk factors. While some arrhythmias are benign, others can lead to serious complications such as stroke, heart failure, or sudden cardiac death (SCD), particularly in high-risk subgroups. Understanding the causes and risk factors that contribute to arrhythmia development across various populations is critical for early detection and prevention.

The Canadian context shows a distinctive profile influenced by both global cardiovascular trends and regional challenges. Among older adults, arrhythmias such as atrial fibrillation (AF) and bradyarrhythmias are common and often associated with conditions like hypertension, coronary artery disease, and diabetes (Bell et al., 2023; Lau et al., 2017). In children and adolescents, congenital or inherited arrhythmias, such as supraventricular tachycardia (SVT) and Long QT Syndrome, are more prevalent, with lifestyle factors having minimal impact at younger ages (Kafali & Ergul, 2022). Athletes form a specific group where both protective and predisposing factors interact—physical activity generally supports cardiac health, but high-intensity training and undiagnosed inherited conditions can elevate the risk of arrhythmias and sudden cardiac death (SCD), especially in young competitive athletes (Katyal et al., 2023; Palermi et al., 2025).

In comparison to other high-income countries like the United States and European nations, Canada exhibits similar arrhythmia patterns but has notable regional differences in access to cardiac screening and electrophysiology services. Nations such as Italy have established systematic ECG screening programs for athletes, resulting in significant reductions in sudden cardiac death (Calvo et al., 2021), whereas Canadian protocols are more decentralized. Moreover, Indigenous populations in Canada experience a higher incidence of cardiovascular disease and arrhythmias due to genetic factors and systemic barriers to healthcare, which is addressed in another section.

This section explores the major causes and risk factors for arrhythmias within the Canadian general population, organized by three key groups: adults, children and adolescents, and athletes. By understanding the population-specific contributors to arrhythmia development, more targeted approaches to screening, prevention, and education can be developed and implemented across healthcare and sport settings.

Adult and Elderly Population

Cardiac arrhythmias are increasingly common among Canadian adults, especially in older populations. Atrial fibrillation (AF), the most frequent sustained arrhythmia, affects more than 500,000 Canadians and is found in over 10% of individuals aged 80 and above (Bell et al., 2023).The lifetime risk of developing AF after the age of 45 is estimated to be one in three (Elliott et al., 2023). Other arrhythmias, such as atrial flutter, bradyarrhythmias (e.g., slow heart rhythms caused by sick sinus syndrome or heart block), and ventricular tachyarrhythmias related to prior heart attacks or structural disease, also become more prevalent with age (Lau et al., 2017). While hospitalizations for arrhythmias have declined in recent years, suggesting improved outpatient management, they continue to contribute substantially to cardiovascular morbidity in aging adults (Humphries et al., 2004; Bell et al., 2023).

Aging itself is a key risk factor, as natural degeneration of the heart’s electrical pathways and increased scarring in heart tissue promote rhythm disturbances. However, age-related comorbidities amplify the risk. Conditions like high blood pressure, coronary artery disease, heart failure, and diabetes contribute to the structural and electrical changes that cause arrhythmias (Lau et al., 2017). Lifestyle-related issues such as obesity, lack of physical activity, and untreated sleep apnea further increase the risk. For instance, long-term obesity contributes to the enlargement and stiffening of the heart’s upper chambers, which can directly lead to AF (Elliott et al., 2023). Additionally, thyroid dysfunction, especially overactive thyroid in older adults, can trigger arrhythmias, particularly in women (Bell et al., 2023). Although most arrhythmias in older adults are acquired, certain families in Canada carry genetic mutations that increase arrhythmia risk. For example, a mutation common in Newfoundland has been linked to arrhythmogenic cardiomyopathy, a disease that can cause life-threatening ventricular arrhythmias (Gollob et al., 2006). These genetic factors often only become clinically significant when combined with age-related changes or other risk conditions.

There are also important sex and gender considerations. While men are more likely to develop arrhythmias like AF, women tend to experience more severe symptoms and have a higher risk of stroke. For this reason, Canadian stroke prevention guidelines assign additional weight to female sex in older adults when assessing stroke risk (Bell et al., 2023; Gillis et al., 2011). Historically, women were also less likely to receive advanced arrhythmia treatments such as catheter ablation, although this gap is beginning to narrow due to updated guidelines and increased awareness (Gillis et al., 2011).

Canadian screening guidelines focus particularly on detecting AF in adults over 65, where the risk of stroke and other complications is highest. Proactive screening during routine health visits, such as checking pulse irregularity or using a simple ECG, can detect new cases of AF in approximately 1–2% of seniors (Andrade et al., 2020). Tools like portable ECG monitors, smartphone apps, and smartwatches are emerging as valuable options, especially for individuals with intermittent symptoms. Several provinces have also piloted community-based screening programs, such as pharmacist-led clinics during flu shot campaigns, with encouraging results (Bell et al., 2023). However, Canada’s national task force has not yet recommended universal ECG screening for asymptomatic individuals, citing insufficient long-term evidence on its effectiveness and cost.

Preventive efforts in Canada emphasize both individual behavior change and system-level interventions. Clinically, the focus is on reducing modifiable risk factors; like improving blood pressure control, managing weight, and treating sleep apnea to prevent or slow the progression of arrhythmias. For patients with AF, treatment typically involves medications to control heart rate or rhythm, as well as anticoagulants to reduce the risk of stroke. Educational campaigns led by organizations such as the Heart & Stroke Foundation of Canada have helped raise awareness that AF is responsible for roughly one in four ischemic strokes in adults over 40 (Heart and Stroke Foundation of Canada, n.d.). These campaigns encourage patients to report symptoms such as palpitations, fatigue, or dizziness, which might otherwise go unnoticed. At the healthcare system level, specialized AF clinics in many provinces streamline care and offer multidisciplinary support. These clinics often include nurse practitioners, pharmacists, and cardiologists working together to help patients monitor their heart rate, manage medications, and understand their risk of complications. The Cardiac Arrhythmia Network of Canada (CANet, n.d) also supports initiatives to improve public understanding and foster integrated care pathways.

To summary, arrhythmias in Canadian adults, particularly the elderly, are shaped by a combination of age-related changes, chronic health conditions, and modifiable lifestyle factors. Sex and gender-specific risks require tailored screening and treatment approaches. While Canada has not implemented universal ECG screening, targeted screening strategies, risk factor modification, and public education efforts are critical to improving outcomes and reducing the burden of arrhythmias in this growing population.

Children and Adolescent Populations

While cardiac arrhythmias are far less common in children than adults, they can still present significant health concerns, particularly when tied to congenital or inherited conditions. The most frequently encountered arrhythmia in otherwise healthy children is supraventricular tachycardia (SVT), which affects approximately 0.2% of the pediatric population, or about 1 in 500 children (Kafalı & Ergül, 2022). In infants, SVT may present as unexplained fussiness, poor feeding, or rapid breathing, with over 50% of cases appearing within the first year of life. Although many infants outgrow SVT, some experience recurrence during later childhood, typically around school age (Kafalı & Ergül, 2022). In contrast to adult populations where lifestyle plays a dominant role, arrhythmias in children are most often the result of structural heart anomalies or inherited electrical disorders. Children born with congenital heart defects (CHD), such as tetralogy of Fallot or those who have undergone complex surgical procedures like the Fontan operation, are at increased risk of developing arrhythmias due to surgical scarring and long-term cardiac remodeling (Kafalı & Ergül, 2022). Additionally, genetic channelopathies such as Long QT Syndrome (LQTS), Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia (CPVT) are rare but critical causes of arrhythmias in children. These inherited conditions can lead to life-threatening ventricular arrhythmias, particularly during exercise or emotional stress, and are a major cause of sudden cardiac arrest in otherwise healthy-appearing youth (Katyal et al., 2023).

Given the lower overall prevalence of arrhythmias in this age group, routine ECG screening is not recommended for all children in Canada. Instead, screening is reserved for those with high-risk symptoms, such as fainting during exertion, unexplained seizures, or palpitations and/or for those with a family history of sudden cardiac death (SCD) or inherited cardiac conditions (Canadian Paediatric Society, 2017). When red flags are identified, pediatricians often refer children for a diagnostic ECG, Holter monitor, echocardiogram, or even genetic testing. For example, an otherwise healthy child who faints while playing sports would typically undergo a cardiac evaluation to rule out underlying arrhythmia. Canadian guidelines emphasize individualized, risk-based screening, alongside education of healthcare professionals, coaches, and families. While large-scale school-based ECG programs are not in place nationally, targeted screening and early diagnosis remain priorities. The Canadian Paediatric Society and pediatric cardiologists encourage awareness campaigns that teach caregivers to recognize signs like repeated fainting, irregular heartbeats, or family history of cardiac events, and to seek evaluation early (Canadian Paediatric Society, 2017).

Management strategies in pediatric populations are often highly effective. For SVT, radiofrequency catheter ablation offers a curative option with success rates above 90% in experienced pediatric centers (Kafalı & Ergül, 2022). For inherited arrhythmias such as LQTS and CPVT, treatment typically includes beta-blocker therapy and, in high-risk cases, implantable cardioverter defibrillators (ICDs). These tools have drastically improved outcomes, allowing many children to lead normal lives with proper monitoring. In some instances, pediatric patients may be temporarily restricted from competitive sports until their condition is well controlled, although recent Canadian and international guidelines now favor shared decision-making and case-by-case assessments rather than blanket bans (Katyal et al., 2023). Several initiatives across Canada also focus on preparedness and prevention in schools and sports environments. Following notable cases of sudden cardiac arrest in youth sports, programs such as the Heart & Stroke Foundation’s AED placement initiative have equipped thousands of schools and arenas with automated external defibrillators (AEDs), while also training staff in CPR and emergency response (Heart and Stroke Foundation of Canada, n.d.). These interventions are especially important since the majority of arrhythmic cardiac arrests in youth occur during physical activity and require immediate defibrillation for survival.

Arrhythmias in children and adolescents, though uncommon, usually arise from structural or genetic issues needing prompt diagnosis. Canadian practice emphasizes risk-based screening, family education, specialized pediatric care, and empowering youth through awareness. Early diagnosis and intervention are crucial for effective arrhythmia management.

Athletic Population

Athletes are often perceived as paragons of cardiovascular health; however, certain individuals face elevated risks of arrhythmias, particularly those with underlying genetic conditions or prolonged exposure to high-intensity training. In younger athletes, arrhythmias are typically rare but can result in severe consequences, including sudden cardiac death (SCD). For youth and competitive athletes under 40, most clinically significant arrhythmias arise from inherited structural or electrical abnormalities, such as hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), and ion channelopathies like Long QT Syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT) (Katyal et al., 2023). These conditions are often silent and can trigger fatal arrhythmias during high-adrenaline activities. The estimated incidence of SCD in young athletes ranges from 1 in 50,000 to 1 in 100,000 athlete-years (Palermi et al., 2025).​ In older athletes, particularly those engaged in endurance sports, arrhythmia risk is often associated with chronic cardiac remodeling. Years of high-volume training can lead to atrial enlargement and fibrosis, increasing the likelihood of AF. Studies have shown that veteran endurance athletes may face a 2 to 5 times higher lifetime risk of AF compared to age-matched non-athletes (Kourek et al., 2024). This condition typically emerges in midlife or later and may impact performance, recovery, and long-term cardiovascular health.

While physical activity is overwhelmingly beneficial, both extremes, intense training without screening in youth and long-term overload in aging athletes, present specific arrhythmia concerns. In Canada, routine ECG screening for athletes is not mandatory, unlike in countries such as Italy where universal pre-participation ECGs have significantly reduced SCD incidence (Calvo et al., 2021). Instead, the Canadian Cardiovascular Society (CCS) and Canadian Heart Rhythm Society (CHRS) recommend a tiered screening approach: all competitive athletes should undergo a detailed personal and family history, as well as a physical exam. If red flags are identified, such as fainting during exertion, abnormal heart sounds, or a family history of SCD, an ECG and specialist referral are warranted (Andrade et al., 2020).​ This risk-based approach balances effectiveness and accessibility. Recent Canadian pilot studies, such as those at Queen’s University, have shown that targeted ECG screening in varsity athletes can successfully detect previously undiagnosed conditions, though the yield of serious findings remains low. Expert interpretation of athlete ECGs is critical to avoid false positives and unnecessary restrictions (Katyal et al., 2023).

Example of a implantable cardioverter-defibrillators (ICD) SystemImage by implantate-schweiz.ch, licensed under CC BY-SA 3.0 CH via Wikimedia Commons.

For athletes diagnosed with arrhythmia conditions, flexible management strategies have become more common. Rather than automatically excluding athletes from sport, current guidelines support shared decision-making between clinicians, athletes, and families. Many individuals with conditions such as LQTS or HCM can safely participate in modified or lower-intensity sport environments, especially when managed with medications like beta-blockers or treated with catheter ablation or implantable cardioverter-defibrillators (ICDs) (Palermi et al., 2025). For example, beta-blockers are effective in reducing ventricular arrhythmia risk in CPVT and LQTS, allowing many young athletes to remain active with regular monitoring.​ Canadian sport organizations and public health bodies have also invested heavily in emergency preparedness. Following high-profile cases of cardiac arrest in youth sport, the Heart & Stroke Foundation of Canada and provincial governments have placed thousands of automated external defibrillators (AEDs) in schools, hockey rinks, and other recreation facilities. Programs like the National AED Initiative have been instrumental in training coaches, referees, and even student-athletes to respond effectively in emergencies. Immediate CPR and defibrillation within minutes can dramatically increase survival chances after a sudden arrhythmic collapse.

Sex and gender differences are also relevant in athlete populations. Male athletes, particularly in high-intensity sports such as basketball and football, have a significantly higher risk of SCD compared to females, approximately four times greater in some studies (Kourek et al., 2024). While this may reflect a higher prevalence of conditions like HCM and greater participation in riskier sports, there is also growing awareness that female athletes may be underdiagnosed or have their symptoms misattributed to anxiety or fatigue. Hormonal influences also play a role; for example, estrogen can increase the QT interval, raising arrhythmia risk in females with inherited LQTS (Katyal et al., 2023).

In essence, the risk of arrhythmia in athletic populations is influenced by a complex combination of genetic predispositions, training intensity, and physiological adaptations. Canadian practices highlight the importance of individualized screening protocols, adaptable management strategies, and comprehensive access to emergency interventions. The increasing focus on education, collaborative decision-making, and sex-sensitive care exemplifies a more athlete-centered approach that prioritizes safety while avoiding unnecessary restrictions on participation.

Arrhythmias in Indigenous Populations

Overview

Cardiac arrhythmias are a growing concern among Indigenous Peoples in Canada, including First Nations, Inuit, and Métis communities, due to their connection with broader cardiovascular disparities. While the general Canadian population sees most arrhythmias emerge in later life, Indigenous populations often experience earlier-onset cardiovascular disease, which increases the risk of developing rhythm disturbances like atrial fibrillation (AF), bradyarrhythmias, and ventricular arrhythmias (Aziz et al., 2022). These disparities are shaped by multiple intersecting factors, including systemic barriers to care, geographic isolation, underdiagnosis, and the ongoing impacts of colonial health policy and structural racism (Vigneault et al., 2021).

Despite these elevated risks, Indigenous Peoples continue to experience delayed diagnosis and reduced access to timely arrhythmia treatment. Screening protocols based on non-Indigenous populations often overlook the earlier onset of disease in these communities, and culturally safe care models remain rare. Furthermore, specific genetic predispositions, such as Long QT Syndrome (LQTS) identified in certain First Nations communities, underscore the importance of family-based screening and awareness (Arbour et al., 2018). This section explores three key themes: the incidence and prevalence of arrhythmias in Indigenous populations, hereditary contributors such as familial LQTS, and the sociostructural conditions that amplify health disparities in rhythm-related cardiac conditions.

Incidence and Prevalence

Indigenous Peoples in Canada experience a disproportionately high burden of cardiovascular disease (CVD), including conditions that increase the risk of arrhythmias such as atrial fibrillation and bradyarrhythmias. Research consistently shows that CVD occurs at younger ages in Indigenous populations, often emerging 5 to 10 years earlier than in non-Indigenous Canadians (Marshall-Catlin et al., 2019; Aziz et al., 2022). This earlier onset leads to greater lifetime exposure to arrhythmogenic risk factors such as hypertension, diabetes, ischemic heart disease, and heart failure. Among Indigenous women specifically, national data show a marked increase in cardiovascular risk. Using data from the Canadian Community Health Survey (2011–2014), Prince et al. (2018) found that among women aged 25–44, CVD prevalence was 2 to 3 times higher in First Nations, Inuit, and Métis women compared to non-Indigenous women. Despite these elevated risks, arrhythmias remain underdiagnosed and underreported, particularly in rural and northern communities with limited access to cardiac diagnostics like ECGs or Holter monitors (Vigneault et al., 2021). Additionally, systemic inequities including healthcare fragmentation, limited access to specialists, and culturally unsafe care environments, contribute to diagnostic delays and missed opportunities for early intervention (Aziz et al., 2022). While national arrhythmia-specific prevalence data remain sparse, the high rate of premature cardiovascular conditions strongly suggests that arrhythmias are a significant but underestimated health concern in Indigenous populations across Canada.

Hereditary Dispositions

Long QT Syndrome (LQTS)Image by PeaBrainC, adapted from Farwell and Gollob (2007), licensed under CC BY-SA 4.0 via Wikimedia Commons.

Beyond social and environmental contributors, hereditary factors also play a critical role in arrhythmia risk among some Indigenous communities. A well-documented case involves a First Nations population in northern British Columbia, where researchers identified a founder mutation in the KCNQ1 gene (p.V205M) that leads to congenital Long QT Syndrome (LQTS) (Arbour et al., 2018). LQTS is a genetic condition that can result in life-threatening ventricular arrhythmias, especially during physical or emotional stress, and is a leading cause of sudden cardiac death in children and young adults with undiagnosed heart conditions (Katyal et al., 2023). In this community, the mutation was found to occur at a rate far higher than in the general population due to a founder effect, where genetic conditions become prevalent in a geographically or socially isolated group (Arbour et al., 2018). Early identification of individuals carrying this mutation can be lifesaving, yet access to genetic testing and specialized cardiac services remains limited in many Indigenous communities across Canada.

Currently, there is insufficient data on the prevalence of inherited arrhythmia syndromes in Inuit and Métis populations. However, the documented presence of familial LQTS and other inherited conditions among First Nations communities highlights the importance of including family history in cardiovascular assessments and ensuring equitable access to cardiac genetic services. Developing culturally appropriate models of care that integrate both Western and Indigenous health perspectives will be key to increasing awareness, screening, and treatment acceptance.

Regional Differences

Cardiovascular care access among Indigenous Peoples in Canada is highly variable by region and is most limited in rural, remote, and northern communities. The majority of literature on cardiovascular outcomes and service access is concentrated in provinces such as Alberta, Manitoba, and Ontario, which house large Indigenous populations; however, substantial gaps persist across all regions (Vervoort et al., 2022). In many northern First Nations and Inuit communities, there are no local cardiologists or advanced diagnostic tools, meaning patients may go undiagnosed or must be transported long distances for evaluation. For instance, no interventional cardiology or cardiac surgery centers exist in the Yukon, Northwest Territories, or Nunavut (Vervoort et al., 2022). Indigenous patients in these territories must often rely on emergency air ambulance transport to reach provincial facilities, contributing to delays in diagnosis and treatment. In fact, nearly 10% of all air ambulance transfers from northwest Ontario are related to cardiovascular emergencies (Vervoort et al., 2022). Additionally, Indigenous communities located far from urban centers face longer wait times and more limited access to follow-up cardiac care, increasing the likelihood of adverse outcomes. Even in urban areas where healthcare infrastructure is more robust, systemic inequities persist. Studies indicate that Indigenous patients are less likely to be referred to specialists and more likely to experience care gaps or complications after treatment (Vervoort et al., 2022). These disparities are influenced not just by distance, but also by institutional barriers and a lack of culturally appropriate care models. Regional variation is thus shaped by both geography and systemic healthcare design, emphasizing the need for tailored, community-specific interventions.

Population Limitations

These limitations include geographic remoteness, fragmented jurisdictional responsibilities, under-resourced health services, and systemic racism within the healthcare system (Vervoort et al., 2022; Browne et al., 2022). Healthcare for Indigenous populations is delivered through a patchwork of federal, provincial, and territorial systems that frequently results in gaps in continuity of care, especially for First Nations communities on reserves. This fragmentation contributes to delays in follow-up after cardiac diagnoses or surgeries and can limit the implementation of preventive screening strategies (Vervoort et al., 2022). In addition, many remote health centers lack ECG equipment or specialized staff to detect and manage arrhythmias effectively.

Compounding these structural issues are experiences of racism and discrimination in clinical environments, which contribute to mistrust and avoidance of the healthcare system (Browne et al., 2022). High-profile cases, such as the death of Joyce Echaquan, have underscored the devastating impact of anti-Indigenous racism in healthcare and the urgent need for system-level reforms. Racism not only deters Indigenous individuals from seeking care but also contributes to unequal treatment once care is accessed. There is also a severe underrepresentation of Indigenous Peoples in the healthcare workforce. Despite making up 4.9% of Canada’s population, only 1.2% of health professionals identify as Indigenous (Vervoort et al., 2022). This lack of representation limits the delivery of culturally safe care and contributes to the continuation of clinical biases. Addressing these limitations requires policy change, community-led healthcare models, investment in diagnostic infrastructure, culturally competent training for all health professionals, and the integration of Indigenous healing practices alongside Western medical approaches. Without such systemic reforms, disparities in arrhythmia care and outcomes will persist across generations.

Screening and Resources

Screening for arrhythmias, particularly atrial fibrillation (AF), remains underutilized in Indigenous communities in Canada despite clear evidence of earlier-onset cardiovascular disease and related complications. While national guidelines recommend opportunistic AF screening beginning at age 65 in the general population, emerging research suggests this threshold is too late for Indigenous adults, who may develop cardiovascular conditions 5–10 years earlier (Aziz et al., 2022; Nahdi et al., 2021). A major limitation to early arrhythmia detection is the inconsistent availability of screening tools, especially in rural and remote Indigenous communities. The absence of ECG machines, Holter monitors, and trained technicians often leads to delayed diagnoses, even when symptoms like syncope or palpitations are reported (Vigneault et al., 2021). Telehealth initiatives, including mobile ECG screening programs, have shown some promise; however, their long-term success depends on integration with culturally appropriate follow-up systems (Nahdi et al., 2021). In response, several researchers and clinicians have proposed community-driven screening frameworks. These include lowering the age threshold for AF screening in Indigenous communities, training Indigenous health workers in arrhythmia detection protocols, and embedding screening into broader wellness assessments that integrate traditional and Western practices (Aziz et al., 2022). A "Two-Eyed Seeing" approach, one that combines Indigenous knowledge systems with biomedical science, is increasingly being endorsed in national cardiovascular policy (Aziz et al., 2022).

Community trust is another essential factor in successful implementation. Historical injustices, including unethical research practices and systemic racism in hospitals, have left many Indigenous people deeply skeptical of healthcare systems. As Vigneault et al. (2021) observed, a lack of cultural safety, stereotyping by healthcare providers, and the perception that hospitals are unwelcoming spaces continue to deter individuals from seeking care, even when arrhythmic symptoms are present. To improve access and trust, screening initiatives must be Indigenous-led or co-developed and embedded within local health governance structures. The First Nations Health Authority (FNHA) in British Columbia offers one such model, embedding culturally grounded education, traditional healing, and preventive screening into community health planning. This approach has shown promise not only in increasing screening uptake, but also in promoting long-term cardiac wellness through relationship-based care (Aziz et al., 2022). Finally, increased funding and health professional training are needed. Few Indigenous-specific screening programs exist at the national level, and Indigenous representation in cardiovascular research remains extremely low (Aziz et al., 2022). Building an Indigenous cardiovascular workforce and ensuring all healthcare professionals receive cultural safety training are key steps in addressing these screening gaps sustainably.

Treatments for Arrhythmias

Overview

In current approaches, treatments for arrhythmia are multifaceted and they aim to prevent comorbidities/complications such as strokes, restore and/or maintain appropriate heart rhythm, and improve symptoms and generally, quality of life (Andel et al., 2024; Steinber and Piccini, 2017). In terms of how it is approached, treatments are dependent on the type of arrhythmia as each can have unique characteristics of rhythm, frequency, and other factors that impact health outcomes (Lizama and Avitali, 2024). As a result, treatment strategies can range dramatically, from conservative lifestyle modification to advanced semi-permanent medical interventions such as implanting medical devices (Fu, 2015; Prystowsky et al., 2020). Examples of these treatments are medications to control heart rate/rhythm, and/or reduce comorbidities, in addition to procedures and devices like pacemakers, and catheter ablation (Fu, 2015; Prystowsky et al., 2020). In order to categorize the approaches, arrhythmias are categorized under supraventricular arrhythmias, ventricular arrhythmias, conduction discords, and cardiac structural variants.

Supraventricular Arrhythmias

When considering supraventricular arrhythmias, which include supraventricular tachycardia (SVT), atrial fibrillation (AF), atrial flutter, and Wolff-Parkinson-White syndrome (WPW), treatment approaches are derived from an emphasis on burden, risks, and recurrences (Page et al., 2016; Moore et al., 2022). Specifically, symptoms burdens, risks of strokes, and increased risks of arrhythmia recurrences make it crucial to consider in terms of treatments (Page et al., 2016; Moore et al., 2022). For arrhythmias such as atrial fibrillation and flutter, pharmacological approaches are preferred since they can aim to target control over cardiac rhythm and rate (Moore et al., 2022; Miller et al., 2019; Al-Khatib et al., 2014). While medications can range and be clinically dependent on context and other external factors, some medications include calcium channel blockers and beta-blockers which can impact cardiac conduction decrease ventricular rate, and result in control over cardiac rate (Miller et al., 2019; Camm et al., 2005).

Radiofrequency Ablation Image by Scientific Animations, licensed under CC BY-SA 4.0 via Wikimedia Commons. Retrieved from Wikimedia Commons.

Beyond pharmacological approaches, catheter ablation is another treatment used for supraventricular arrhythmias due to its effectiveness (Marine, 2007; Combes et al., 2017). Specifically, this treatment involves the use of radiofrequency ablation or cryoablation (ie. cold tissue destruction) through a catheter that is inserted via a blood vessel and guided to near the target cardiac tissue (Marine, 2007; Combes et al., 2017). The aim of this treatment is to block abnormal electric conduction through the elimination of arrhythmogenic circuits (ie. the abnormal route of conduction) in the heart, via target tissue scaring (Marine, 2007; Combes et al., 2017). As an example, catheter ablation is used in atrial fibrillation, to create scar tissue to isolate the pulmonary vein which is shown to result in the correlation of reduced triggering of AF (Mohanty et al., 2023). Compared to pharmacological approaches, research has observed that catheter ablation can result in an increased reduction in arrhythmia reoccurrence and improve quality of life (Combes et al., 2017). Ultimately, supraventricular arrhythmias can be approached in a multitude of ways and hence, a patient-centered approach should be considered to derive the best treatment based on a well-rounded approach.

Ventricular Arrhythmias

Example  of an Automatic External Defibrillator (AED) Set Up Image by PhilippN, adapted from Blodpumpe.png and Gray1219.png, licensed under CC BY-SA 3.0 and the GNU Free Documentation License. Retrieved from Wikimedia Commons.

Unlike supraventricular arrhythmias, ventricular arrhythmias are more deadly in some cases and hence, they require an effective and swift treatment approach (Huang et al., 2024; Fernandes et al., 2019). Ventricular arrhythmias include ventricular tachycardia (VT), ventricular fibrillation (VF), and idiopathic ventricular rhythms. Since these arrhythmias can often occur in the context of major cardiovascular damage, such as myocardial ischemia (ie. heart damage caused by lack of oxygen), they can result in sudden cardiac death (Huang et al., 2024; Fernandes et al., 2019). The acute treatment of severe ventricular arrhythmias (which excludes idiopathic rhythms) is to use immediate defibrillation in order to effectively restore rhythm through a controlled electrical shock to the heart (Neumar et al., 2015). It should be noted that a delay in defibrillation can decrease the odds of survival by up to 10% for every minute and hence, an immediate approach is crucial (Neumar et al., 2015; Cheskes et al., 2020).

After experiencing a ventricular arrhythmia such as VF or VT, the prevalence of recurrent can be up to 20% for the first year, and 50% for the second year if left with no treatments (Deyell et al., 2020). Although the recurrent prevalence can be dependent on external factors such as lifestyle habits and comorbidities, the severity and risk of sudden death make it crucial to plan a preventative strategy that addresses these concerns (Deyell et al., 2020). Due to this, a treatment approach to severe ventricular arrhythmias is the implantation of a Cardioverter-defibrillator (ICD) since they provide constant monitoring for signs of arrhythmias and provide the same precise and effective defibrillator shock at any location (Tran et al., 2023; Poole et al., 2020).  To elaborate further, this approach has been observed by researchers to result in approximately 20% reduction in mortality for ventricular arrhythmia (Tran et al., 2023; Poole et al., 2020). It should be noted that to decrease the burden and increase the quality of life, individuals with ICDs can also use pharmacological (ex. amiodarone) and further procedural approaches (ex. catheter ablations to address the frequency of ICD discharges, and reduce arrhythmia burden such as dizziness (Tran et al., 2023; Poole et al., 2020). Considering the benefits of ICDs, some limitations are also observed such as limitations to access if patients have other implantations (Tran et al., 2023; Poole et al., 2020). In contrast to severe ventricular arrhythmia, idiopathic ventricular rhythms are often benign, and hence, no major treatments are approached however, monitoring and exercises are observed to be appropriate management strategies to ensure early detection and prevention of adverse symptoms (Sirichand et al., 2017).

Conduction Arrhythmias (Bradyarrhythmia)

Arrhythmias that are categorized under conduction disorders involve a delay (or in some instances complete) interruption in the cardiac electric circuit (De Luca et al., 2019; Willich and Goette, 2014; Morovatdar et al., 2021). Due to this, these arrhythmias involve various levels of severity and nodes such as the sinoatrial (SA) and atrioventricular (AV) nodes (De Luca et al., 2019; Willich and Goette, 2014; Morovatdar et al., 2021). It should be noted the treatment approaches to conducting arrhythmias can vary due to the observed range in severity of these arrhythmias (De Luca et al., 2019; Willich and Goette, 2014; Morovatdar et al., 2021). As an example. 1st degree AV blocks are typically benign while 3rd degree AV blocks can cause symptoms of dizziness, and fatigue (De Luca et al., 2019; Willich and Goette, 2014; Morovatdar et al., 2021).

Treatment approaches that involve severe conduction arrhythmias, such as high-degree AV blocks, would be to use pharmacological interventions to block vagal stimulation to impact heart rate (De Luca et al., 2019; Willich and Goette, 2014; Morovatdar et al., 2021). In more severe cases where this intervention is not effective, invasive measures such as transvenous pacing are required which electrical shocks and paces the heart through a wire that is inserted through the veins (De Luca et al., 2019; Willich and Goette, 2014; Morovatdar et al., 2021). It should be noted that this is only a temporary treatment which is followed by an implementation of a pacemaker, an internal device that provides consistent electrical stimuli to the heart and ensures proper synchronized contractions (De Luca et al., 2019; Willich and Goette, 2014; Morovatdar et al., 2021).

Cardiac Structural Variations

In contrast to the majority of the other approaches, there are no direct treatments for structural variations in the heart, such as left ventricular hypertrophy (LVH), right ventricular hypertrophy (RVH), and atrial enlargement (Ng et al., 2015; Barral et al., 2015). However, management strategies for these structural changes involve addressing the associated risks of other cardiovascular diseases, and health concerns (Ng et al., 2015; Barral et al., 2015). As an example, there has been an observed association between right ventricular hypertrophy and increased prevalence of hypertension, and hence, management often involves monitoring and addressing these risks (Barral et al., 2015; Ifiora et al., 2023). Uniquely, education becomes important for early detection, awareness, and improvement of quality of life (Barral et al., 2015; Ifiora et al., 2023).

Exercise Considerations for Arrhythmias

Overview

Over the recent decades, more considerations have been taken into structure exercise interventions and cardiovascular diseases such as arrhythmias (Almeida, 2019; Manolis and Manolis, 2016). As a result, researchers have reported many benefits to exercise in the context of arrhythmia management, ranging from enhanced autonomic regulation to reduced inflammation and mental well-being (Almeida, 2019; Manolis and Manolis, 2016). Considering this, exercise may not be suitable on all occasions since can also increase the prevalence of exercise-induced arrhythmias due to extreme physical exertions (Almeida, 2019; Manolis and Manolis, 2016). Due to this, exercise considerations can vary depending on the characteristics of the arrhythmia however, well-rounded approaches would include aspects of risk stratification, comprehensive pre-participation evaluation, precautions, and education prior to exercise no matter the arrhythmia type (Almeida, 2019; Manolis and Manolis, 2016).

Considerations Based on Arrhythmia Characteristics

Considering supraventricular arrhythmias, such as AF and SVT, exercise programs integrating low to moderate aerobic training can be beneficial since they can improve functional capacity, and quality of life, and reduce the burden of symptoms (Almeida, 2019; Quinto et al., 2023). Specifically, individuals with AF may demonstrate impaired exercise tolerance due to burn symptoms which can be addressed with aerobic exercises to reduce burden and increase quality of life (Manolis and Manolis, 2016; Quinto et al., 2023). Performing risk stratification is crucial and if not properly may highlight some additional considerations such as the use of medication such as beta-blockers which can impact exertion scales (Almeida, 2019; Quinto et al., 2023; Dorain et al., 2020). As for ventricular arrhythmias, individuals with severe cases require extensive risk assessment and often require collaboration with their clinic team alongside other external members/teams (Quinto et al., 2023; Dorain et al., 2020). For individuals who have ICDs, exercise can be beneficial in enhancing functional capacity, and reducing arrhythmia recurrence however, extra considerations are required (Dougherty et al., 2015). As an example, monitoring the heart is crucial during exercise to ensure the heart rate does not reach the ICD threshold for discharge (Dougherty et al., 2015). Similar to other approaches, risk stratification is also crucial for conduction disorders since some severe cases may require clinical interventions prior to participation (Quinto et al., 2023; Dorain et al., 2020). Uniquely, the impact of these arrhythmias on heart rate results in the inability to use heart rate as an association with exercise intensity and individual exertion due to sinus node dysfunction (Quinto et al., 2023; Dorain et al., 2020). As a result, exercise programs integrate low to moderate aerobic training using blood pressure measurements as the main biomarkers for measurements of intensity and exertion (Quinto et al., 2023; Dorain et al., 2020). It should be noted that individuals with implantations should avoid upper body resistance exercises for the beginning two months to prevent complications such as implantation dislodgement (Dougherty et al., 2015). As for the cardiac structural variations, exercise approaches need to be individualized based on the variation (Quinto et al., 2023; Dorain et al., 2020). Similar to the other types, risk stratification is crucial and requires one to be well-rounded (Quinto et al., 2023; Dorain et al., 2020; Almeida, 2019). As an example, it should include structural cardiac imaging, electrocardiography, history, and other factors such as approval from a family doctor depending on context (Almeida, 2019; Manolis and Manolis, 2016). It should be noted that in all types, there might be some cases where exercise risks are not matched by the benefits and hence, should not be pursued (Almeida, 2019; Manolis and Manolis, 2016).

Emerging Studies

Example of the iRhythm ZIO® XT PatchImage by KamenG, showing a patient wearing the iRhythm ZIO® XT Patch nine days post-placement. Licensed under CC BY-SA 4.0. Retrieved from Wikimedia Commons.

In recent research, advancements in technology have considerably impacted the approach to monitoring and interpretation of arrhythmia electrocardiographs (ECG) (Elul et al., 2021; Kennedy, 2024). Specifically, recent research has trained Artificial Intelligence (AI) models with machine learning algorithms (ie. parameters to learning) derived from ECG data in order to be able to autonomously identify abnormalities and associations with arrhythmias (Elul et al., 2021; Kennedy, 2024), As a result, these models can use as early detection systems to arrhythmias such as AF that can be challenging for naked human eyes to detect (Elul et al., 2021; Kennedy, 2024). The benefit of this new approach is that interpretation can yield higher sensitivity and specificity using AI models with cardiologists (Kennedy, 2024). As an example, AI model interpretations of atrial fibrillation ECGs resulted in 0.76 sensitivity and 0.97 specificity compared to just cardiologists which resulted in 0.74 sensitivity and 0.94 specificity (Kennedy, 2024). As a result of these benefits, AI has been observed to be integrated into the newest ECG models with Canada promoting this movement through publishing guidance and policies regarding AI medical devices (Government of Canada, 2025). Alongside the benefits, research has also highlighted major limitations to this technology such as the need for high-quality large data sets and a lack of transparency in the interpretation process (Elul et al., 2021; Kennedy, 2024).

Another technological advancement that has recently seen interest in research has been the integration of ECG into wearable technologies to achieve continuous non-invasive rhythm monitoring (An et al., 2024; Amami et al., 2022). As a result, this can be beneficial since can detect no symptomatic arrhythmias throughout the day and aid in detecting anomalies that can be crucial in diagnosis (An et al., 2024; Amami et al., 2022). Additional wearable noninvasive technologies can be beneficial as they can provide real-time data remotely and aid individuals in automatically asking for medical assistance during arrhythmic events (An et al., 2024; Amami et al., 2022). These wearable technologies can also range in modalities from medical chest devices to undershirt clothing that has embedded electrodes. Depending on the modality, this approach is observed to correctly identify AF by up to 80% which calls for further research in enhancing accuracy (An et al., 2024; Amami et al., 2022).

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