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It is possible that in the coming years we will see the number of adults with arrhythmias rise, because long- term arrhythmias may be among the permanent changes in function that some survivors of COV ID-19 experience. 40 m a s s a g e & b o d y w o r k n o v e m b e r / d e c e m b e r 2 0 2 0 Other complications associated with arrhythmias include dementia from prolonged ischemia in the brain and heart failure related to myocardial damage. TREATMENT FOR ARRHYTHMIA When the heart rhythm is suddenly and seriously interrupted, it can sometimes be restored through the administration of an electrical shock. Depending on the circumstances, this may be a cardioversion procedure (designed to restore a normal rhythm) or defibrillation (specifically targeted at ventricular fibrillation). Most ongoing arrhythmias are manageable with medications, devices, or minor surgery. Treatment begins with anti-arrhythmic drugs that work to restore proper movement of electrolytes in myocardial cells. Antiplatelet drugs or anticoagulants might also be prescribed to reduce the risk of blood clot formation inside the heart chambers. And drugs to manage cardiac function and blood pressure might also be called for if the heart has sustained structural damage. If these interventions are not successful, a cardiac ablation may be performed. This procedure uses a catheter to enter the heart and damage tiny areas that are generating anomalous signals, so the impulse pathways are returned to normal. Some patients may require the implantation of a device to maintain or restore a healthy heart rhythm. A pacemaker mimics the work of the SA node to generate the impulses that cause the heart to function. An implantable cardiac defibrillator (ICD) can use high- energy pulses to reestablish a heart rhythm that has been interrupted. ARRHYTHMIAS AND COVID-19 We have known for some time that COVID-19 can affect the heart. Ventricular tachycardia and fibrillation were the cause of death for many early victims of the infection, and medical intervention in these emergencies was highly risky to both patients and health-care professionals. Autopsies show that the virus can directly invade myocardial cells. Immune and inflammatory reactions, including the cytokine storm seen with other organ failure, can exacerbate heart damage. In a study of 100 previously healthy patients (average age of 49 years), 78 had long- term structural changes in the heart, and 76 had biomarkers that indicated heart attacks. 1 Other studies suggest that more than 40 percent of COVID-19 survivors with severe infections have long-term changes in heart function. 2 While people with the most extreme infections (including those who lost their lives) clearly have the most severe consequences to their cardiac function, those who experience milder bouts of COVID-19 also show signs of damage that may be permanent. Many survivors have been diagnosed with myocarditis (heart inflammation) that can alter function and open the door to arrhythmias. It is common to hear complaints of fatigue and palpitations with only mild exertion, even weeks or months after the infection has subsided. Some cardiologists worry that these patients with arrhythmias now may have a higher risk for heart failure or other cardiovascular complications later. That said, it is important to point out that other severe infections can cause heart problems; SARS-CoV-2 is not unique in this way. And a large-scale study of COVID-related cardiac arrests and arrhythmias concluded that while the infection was a contributor to the problem, it was not the only cause. 3 IMPLICATIONS FOR MASSAGE THERAPY What does all this mean for massage therapists? Some clients with a history of arrhythmia have only occasional symptoms and no particular limitations in cardiovascular health or activity. Others may have to use medications to manage their risk for stroke or heart attack. Still others may require surgical intervention to affect how electrical impulses move through the heart. When we weigh the risks and benefits of working with a client who has some form of arrhythmia, we must consider a few issues: • What other cardiovascular issues are in their health history, and what have they done to treat them? • What is their allostatic capacity—that is, how resilient are they, and how much challenge to homeostasis can they comfortably accommodate? • What medications do they use, and what side effects do they have? If we know these answers, we can design and implement a session that mitigates risks and maximizes benefits. For instance, if the client exercises vigorously and raises their heart rate on a regular basis, it's hard to imagine that massage therapy could further tax this cardiovascular system in any negative way. But if exercise is uncomfortable and leaves them with chest pain and shortness of breath, massage should be less demanding.

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