ASK THE DOCTOR: My heart beats slowly - should I be worried?
I have been wearing a heart rate monitor round my chest before and after exercise, which I have been doing two to four times a week. My heart rate went down to 36 recently, then crept back up to 52 before exercising. I have also felt a bit lightheaded. Should I get it checked out? I'm 40.
Grant Burton, by email.
It's s important to recognise that sinus bradycardia can be a symptom of a number of conditions
For most people, the heart beats at 60-100 times per minute when it's at rest - this is known as the sinus rhythm. It is set by the sinoatrial node, the area of the heart that generates the impulses triggering each heartbeat.
When the rate is below this, as it is sometimes in your case, this is referred to as sinus bradycardia. It is quite possible for this to happen to healthy people, such as in those who are very physically fit - a fitter heart can pump more blood with each beat, so fewer beats per minute are needed for it to do its job.
A slower heartbeat may also occur naturally during sleep.
But it's important to recognise that sinus bradycardia can be a symptom of a number of conditions, so you should therefore get it checked out. One possibility is so-called sick sinus syndrome, where the sinoatrial node malfunctions due to disease.
There are many conditions that can have this effect, including sarcoidosis (a rare condition that causes small patches of red and swollen tissue to develop in the organs), or inflammatory heart conditions such as rheumatic fever.
An underactive thyroid can also result in a slow heart rate, because the hormone it secretes - thyroxine - influences the heart rate.
Dr Scurr recommends an electrocardiogram to record pattern of electrical activity of the heart and blood test
Medications can cause bradycardia, and again there is a long list: beta blockers, opioid painkillers and chemotherapy drugs, are just some of the possibilities.
Bradycardia may also occur in patients with obstructive sleep apnoea - where the tissues of the throat relax and narrow during sleep, interrupting normal breathing.
It can also follow a stroke in some cases, or infectious conditions including Lyme disease, typhoid and dengue fever.
In most patients with sinus bradycardia there are no additional symptoms, unless it is due to a cause such as those listed above. However, a slow heartbeat can cause feelings of lightheadedness - as you have experienced - or even fainting.
An underlying cause will probably come to light when your doctor examines your history. And if none of the above applies, the conclusion may well be that you are an athletic person in whom no further intervention is required.
However, as you are 40 you must undergo an electrocardiogram to record the exact pattern of the electrical activity of your heart and a blood test to check for an underactive thyroid and for other conditions such as silent infection.
Do see your doctor for an initial evaluation, but do not be alarmed.
Bisphosphonates are used to prevent and treat osteoporosis and work by inhibiting the process by which bone is broken down
My sister, aged 77, suffers from osteoporosis and has taken the bisphosphonate alendronic acid for ten years. You have previously said that people usually stop taking this medicine after five years. Can any damage be caused by staying on this drug? She also takes medication for diabetes and blood pressure, and the blood thinner warfarin. She has complained of losing her taste, often feels sick, and takes strong painkillers for back pain. Her GP is varying her painkillers to see if they are behind her problems. Can you advise?
Name and address withheld.
Bone is a living tissue that is constantly being broken down and then re-formed.
Osteoporosis (where bones become weaker and thinner, making them more prone to breaking) occurs when there is a long-term imbalance between these two processes.
Bisphosphonates are used to prevent and treat osteoporosis and work by inhibiting the process by which bone is broken down. They have relatively few side-effects when you take them orally, but these can be unpleasant to say the least, and I have some sympathy with your concern for your sister.
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Some patients experience acid reflux and inflammation of the oesophagus, though these are unusual if the tablets' instructions are followed carefully.
There are some other even less common potential side-effects, such as low calcium levels - the risk is greater in patients who have vitamin D deficiency (vitamin D helps the body absorb and use calcium) or too little calcium in their diet.
Most doctors prescribing a bisphosphonate tablet also ask their patients to take a supplement of calcium with vitamin D.
A rare complication of bisphosphonate treatment is severe musculoskeletal pain - this can come on at any time, at the start of treatment, or later.
Even more rare is osteonecrosis of the jaw, where the jaw bone breaks down. Good dental care and hygiene minimise the risk.
Finally, I must mention the complication of atypical fracture of the femur (the thigh bone) - where the bone fractures gradually and spontaneously, without any trauma. This is the one side-effect of bisphosphonate therapy that is specific to long-term treatment, ie, treatment lasting more than seven years.
It seems paradoxical that drugs given to strengthen bone can actually cause the bone to become brittle, but it seems to be linked with over-suppression of bone turnover (the process by which the bone is broken down and re-formed).
This complication affects around just 50 in 100,000 people taking the drug, and it is usually preceded by pain in the groin or thigh, lasting some weeks. This is something to watch out for in your sister.
The potential benefits must be weighed up against these relatively uncommon hazards of long- term treatment.
Treatment for ten years is not unusual, even though most doctors tend to stop at five years if the patient's bone mineral density is stable and they suffered no spontaneous spinal fractures before treatment.
However, in women at high risk of fracture the studies show there are benefits without an increased risk of adverse effects when treatment is continued for ten years.
Your sister's doctor will no doubt consider whether it is the bisphosphonate that's causing her symptoms. On the other hand, it may be the drug that he least wishes to stop, at least for now.
By the way ... The NHS learns nothing from history
The NHS is about 50,000 short of the number of clinical staff needed to provide a safe and effective service, a report by the medical protection Society (MPS) warned recently.
By 'clinical staff', we mean doctors, nurses, dietitians, physiotherapists and all of those professionals involved in the care of sick patients.
This is a matter of great concern, given the massive cutbacks we are facing in healthcare, not to mention the push for routine care to be provided on a seven-day basis, despite the revelation that the data upon which this need is based now appears to be questionable.
These various pressures, which threaten the quality and safety of medical care, only serve to confirm my view that the Department of Health and NHS England have very little grasp of how to run a healthcare system.
This was driven home to me this month when I was reading about Sir Frank Whittle, the inventor of the jet engine. Sir Frank's engine first took to the skies in 1941, yet the Air Ministry decided that jet engines were 'impracticable' and dismissed this technological advance.
However, because the concept was not deemed worthy of being kept secret, despite it being wartime, Germany was free to read Frank Whittle's patent.
They did recognise the potential and in three years had an operational jet fighter.
This piece of history mirrors the lack of vision that bedevils the development of the NHS.
Did no one realise, for instance, the devastation that the European Working Time Directive (which puts a block on the number of hours doctors can work) would cause as long-refined, and carefully evolved, consultant-led teams were dissolved as rotas were forcefully created. Has there been no recognition that as 60 per cent of all medical students are women there might be some subsequent manpower considerations, for example, if they choose to work part-time after having children?
And with general practice currently getting less than 10 per cent of the overall NHS budget (although there are now promises of more - but how much?) and healthcare being pushed out into the community, did no one foresee there might be consequences?
Namely, that GPs are under such strain that many are retiring early and fewer young doctors are choosing general practice as a career. None of this will change until politicians and the powers-that-be learn to look beyond their noses, and see the bigger picture - or become visionaries.
Don't hold your breath.
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