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  Arrhythmias/Dysrhythmias  
 
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Signs, symptoms and indicators | Conditions that suggest it | Contributing risk factors | Other conditions that may be present | Recommendations

 

An arrhythmia is a change in the rhythm of your heartbeat. The heart can beat too fast (tachycardia) or too slow (bradycardia). An arrhythmia can also mean that your heart beats irregularly (skips a beat or has an extra beat). At some time or another, most people have felt their heart race or skip a beat. These occasional changes can be brought on by strong emotions or exercise. They usually are not a cause for alarm. Arrhythmias that occur more often or cause symptoms may be more serious and need to be discussed with your doctor.

What causes an arrhythmia?
The heart has 4 chambers. The walls of the heart contract to push blood through the chambers. The contractions are controlled by an electrical signal that begins in the heart's natural "pacemaker" (the SA node). The rate of the contractions is influenced by nerve impulses and hormones in the blood. A problem here, or signals coming from elsewhere, can cause an arrhythmia.

Minor arrhythmias may be caused by excessive alcohol use, smoking, caffeine, stress or exercise. The most common cause of arrhythmias is heart disease, particularly coronary artery disease, abnormal heart valve function and heart failure. However, arrhythmias can occur for no known reason.

Is an arrhythmia serious?
In most people, arrhythmias are minor and not dangerous. A small number of people, however, have arrhythmias that are dangerous and require treatment. Arrhythmias are also more serious if you have other heart problems. In general, arrhythmias that start in the lower chambers of the heart (the ventricles) are more serious than those that start in the upper chambers (the atria). Your doctor will talk with you about the type of arrhythmia you have and whether you need treatment.

Tests available
One test that may required for diagnosis is an electrocardiogram, also called ECG or EKG. You may need to take a treadmill test while your heart is monitored, or monitor your heart while you do your daily activities. This can be done with a Holter monitor for 24 hours. Other equipment is available for use when monitoring for more 24 hours. Further testing may be necessary.

Types of arrhythmias

  • Atrial fibrillation. Atrial fibrillation is the most common cardiac arrhythmia. The risk of developing atrial fibrillation increases with age — AF affects four percent of individuals in their 80s. An individual may spontaneously alternate between AF and a normal rhythm (paroxysmal atrial fibrillation) or may continue with AF as the dominant cardiac rhythm without reversion to the normal rhythm (chronic atrial fibrillation). Atrial fibrillation is often asymptomatic, but may result in symptoms of palpitations, fainting, chest pain, or even heart failure. These symptoms are especially common when atrial fibrillation results in a heart rate which is either too fast or too slow.
  • Paroxysmal atrial tachycardia (PAT). The heart has episodes when it beats fast, but regularly. This type of arrhythmia may be unpleasant but is usually not dangerous. PAT is an example of an arrhythmia where the abnormality is in the electrical system of the heart, while the heart muscle and valves may be normal. PAT is susceptible to alcohol excess, stress, caffeine, an overactive thyroid or excessive thyroid hormone intake, and certain drugs.
  • Ectopic beats. The heart has an extra beat. Treatment usually is not needed unless you have several extra beats in a row and/or other problems with your heart (such as heart disease or congenital heart failure).
  • Ventricular tachycardia and ventricular fibrillation. The heart beats too fast and may not pump enough blood. These types of arrhythmias are very dangerous and need immediate treatment.
Conventional Treatments
Treatment depends on the type of arrhythmia you have. Some mild arrhythmias require no treatment. Other arrhythmias can be treated with conventional drugs, a pacemaker, defibrillation, radiofrequency ablation or surgery.

Patients with arrhythmias are commonly treated first with anti-arrhythmic medications such as digoxin, beta-blockers and other types of drugs to regulate their heartbeat. When medications fail to control the condition or their side effects are not well tolerated, other surgical and non-surgical treatments are considered.

"Catheter cryoablation has been performed for several years in the United States and Europe but its benefits, compared to other types of treatments for high-risk arrhythmias, are not widely known by the general public and some healthcare professionals." This quote is from Dr. Kerwin. One of Kerwin's patients is 57-year-old Peter Nyquist of Weatherford, TX, who works for the Federal Aviation Administration as an air traffic control specialist. He had a type of arrhythmia called atrial fibrillation, an extremely rapid and uncoordinated heart rhythm that originated in all four of his pulmonary veins.

He first noticed more than a decade ago that he felt very tired and "washed out," but it took years before he knew why or what could be done. An Internet search led him to Kerwin, who performed a catheter cryoablation in 2006. "I have my life back … it's unbelievable," Nyquist said.
 

 
 

Signs, symptoms & indicators of Arrhythmias/Dysrhythmias:
 
 
Symptoms - Cardiovascular  Having minor PVCs
  Heart racing/palpitations
  Pain in chest or left side

Symptoms - General

  General dizziness
  Fatigue on light exertion
 An inefficient pumping action by the heart can result in rapid fatigue.

Symptoms - Respiratory

  Air hunger
 
 

Conditions that suggest Arrhythmias/Dysrhythmias:
 
 
Symptoms - Cardiovascular  Having ventricular/having atrial fibrillation or having PAT
 
 

Risk factors for Arrhythmias/Dysrhythmias:
 
 
Allergy  Environmental Illness / MCS
 An irregular or rapid heart beat and awareness of your heart beating are listed as possible symptoms of environmental illness.

Diet

  Dehydration

Environment / Toxicity

  Zinc Toxicity

Hormones

  Elevated DHEA
 A Dr. Sahelian reports in a 1998 letter to the Annals of Internal Medicine, a case report of heart rhythm irregularities with the use of DHEA. It was the first time such association was made and published. The case report mentioned heart palpitations that occurred in Dr. Borken who was taking 25mg of DHEA daily. When he stopped the DHEA, the palpitations went away, when he resumed the DHEA, the palpitations recurred. [Ann Intern Med. 1998 Oct 1;129(7):588]

Infections

  Clostridium Difficile
 An abnormal heart rhythm may occur in serious cases of Clostridium difficile infection.

  Lyme Disease

Metabolic

  Problem Caused By Being Overweight
  Hemochromatosis (Iron overload)
 Cardiac arrhythmia occurs in about 7% of symptomatic hemochromatosis patients.

Nutrients

  Hypokalemia / Potassium Need
  Selenium Requirement
 In one investigation, patients with long term low levels of selenium who had arrhythmias and other cardiac disorders showed significant improvement (and in one case the arrhythmia "disappeared dramatically") after supplementing with selenium.

  Magnesium Requirement
 Myocardial magnesium was measured in 8 young patients (mean age 32) with ventricular tachycardia of less than 30 seconds in duration who underwent endomyocardial biopsy. Myocardial magnesium content was lower in the 4 with cardiomyopathic and dysplastic lesions than in the 4 with inflammatory lesions (myocarditis) and 8 controls. 10gm magnesium over 24 hours caused a resolution of ventricular tachycardias and a greater than 80% reduction in ventricular extrasystoles. No response was seen in the 4 patients with inflammatory lesions. [Lancet: 1019, 1987]

In another study of heart failure patients, those with the most frequent initial ectopic beats prior to a magnesium infusion had the most significant decrease with half the number of premature ventricular contractions after the infusion. Almost all the patients who had an increase in serum magnesium greater than the median value of 0.75 mg/dl showed a decrease in premature ventricular depolarization. [ Emergency Medicine, May 1994; p.53]

Magnesium deficient individuals may have an increased risk to arrhythmias, in particular premature ventricular contractions
related to impairment of the sodium-potassium-ATPase pump.

  Copper Deficiency
 Ventricular premature beats have disappeared after supplementation with copper in a few cases. In one of these people, supplementing with zinc made the arrhythmia worse, confirming previous observations that excessive zinc intake may lead to copper deficiency and arrhythmia.

Respiratory

  Sleep Apnea
 Sleep apnea can also result in cardiac arrhythmias. Most often, the heart slows while the person stops breathing, and increases when the apneic episode ends. In 90% of those patients studied with nocturnal bradyarrythmia (slowed heart rate), there was no sign of heart rhythm abnormalities while awake. Bradyarrhythmias occurred only during sleep and varied considerably in frequency and severity. [American Heart Journal 2000; 139: pp.142-8]
 
 

Arrhythmias/Dysrhythmias suggests the following may be present:
 
 
Cell Salts  Cell Salt, Mag Phos Need

Circulation

  Hypercoagulation (Thickened Blood)
 In atrial fibrillation, the risk of thickened blood and subsequent stroke is increased. This is the reason why an anticoagulant is so frequently used.

Metabolic

  Problem Caused By Being Overweight

Respiratory

  Sleep Apnea
 Sleep apnea can also result in cardiac arrhythmias. Most often, the heart slows while the person stops breathing, and increases when the apneic episode ends. In 90% of those patients studied with nocturnal bradyarrythmia (slowed heart rate), there was no sign of heart rhythm abnormalities while awake. Bradyarrhythmias occurred only during sleep and varied considerably in frequency and severity. [American Heart Journal 2000; 139: pp.142-8]
 
 

Recommendations for Arrhythmias/Dysrhythmias:
 
 
Amino Acid / Protein  L-Carnitine
 In a controlled trial, patients with exercise induced angina received L-carnitine at a dose of 2gm per day. After 6 months, compared to controls, they had a significant reduction in the number of premature ventricular contractions at rest and increased tolerance during exercise. Improvements were noticeable after 1 month and became more pronounced with continued treatment. [Drugs Exp Clin Res 17: pp.225-35, 1991]

  Taurine
 Taurine has been found to be particularly concentrated in the heart with its levels exceeding the combined total of all other amino acids. During active stress the levels of taurine go up in the heart. Levels go down after an MI or ischemic attack. In Japan, taurine is used to treat various types of heart disease. Some arrhythmias may require IV administration.

Animal-based

  Fish Oil / Krill
 Residents of a nursing home took either a daily two-gram fish oil supplement or soy oil supplements for six months. Those who took the fish oil did not experience any decline in heart rate variability. In contrast, those who took the soy oil experienced only "marginal, nonsignificant" benefits.

The omega-3 polyunsaturated fatty acids found in fish oil could, therefore, act as a preventive measure against arrhythmia and sudden death, especially among those exposed to ambient air pollution. [American Journal of Respiratory and Critical Care Medicine December 15, 2005; 172(12): 1534-1540]

Botanical

  Goldenseal (Hydrastis canadensis)
 Berberine is the principal active ingredient in the herb goldenseal ( Hydrastis Canadensis ). Studies show that the alkaloid berberine is beneficial for ventricular arrhythmias due to lack of oxygen. Evidence also suggests that berberine administration can help prevent the onset of re-entrant ventricular tachyarrhythmias and sudden coronary death after myocardial ischemic damage.

  Olive Leaf Extract
 European researchers have reported that olive leaf extract could increase blood flow in the coronary arteries and relieve arrhythmias. There is some testimonial evidence in support of this claim.

  Hawthorn (Crataegus oxycantha)
 Hawthorn has been used traditionally for treating arrhythmias, although its use for this purpose has not been studied in humans.

Dental

  Remove Wisdom Teeth
 Dentists report that the removal of a dead wisdom tooth as well as infected bone in the area has on occasion caused an arrhythmia to disappear.

Detoxification

  Heavy Metal Detoxification / Avoidance
 Some doctors have reported arrhythmias improving after mercury amalgam filling removal and systemic treatment with heavy metal chelators. [Alternative Medicine Digest]

  Chelation Therapy
 The claim is made by doctors administering EDTA chelation therapy that cardiac arrhythmias frequently disappear when a sufficient number of treatments have been given. This may be due to the magnesium content.

Diet

  Alcohol Avoidance
 Atrial fibrillation can be caused by alcohol.

  Caffeine/Coffee Avoidance
 Preventicular contractions (PVCs) can be caused by caffeine.

  Artificial Sweetener Avoidance

Drug

  Conventional Drugs / Information
 In atrial fibrillation, medications are available to restore and maintain a normal heart rhythm. Additionally, blood thinning agents, such as Coumadin (warfarin), are prescribed to reduce the risk of clots forming or stroke. The results of a study were announced showing that an experimental orally administered anticoagulant, Ximelagatran (Exanta™, Exanta™, AstraZeneca) has been shown to be a highly effective alternative to well-controlled warfarin for stroke prevention in patients with non-valvular Atrial fibrillation, not only resulting in a greater reduction of strokes and systemic embolic events in these individuals, but also caused less bleeding while providing a safer, easier-to-administer agent without the need for monitoring. [Halperin JL., Am Heart J. September 2003;146(3): pp.431-8]

For PVCs, unless there is structural heart damage, no action may be required. If symptoms are troubling, a mild anxiolytic drugs or beta-adrenergic blockers may be helpful. Long-term treatment of ventricular tachycardia may require the use of oral anti-arrhythmic medications (such as procainamide, amiodarone, or sotalol). Anti-arrhythmic medications, however, may have severe side effects, and their use is currently decreasing in favor of other treatments.

Many types of tachycardias respond well to anti-arrhythmic medications. Although not a cure, they can reduce episodes of tachycardia or slow down the heart when an episode occurs. These medications include:
  • Sodium channel blockers:
  • Sodium channel blockers slow the conduction of electrical impulses through the heart. These drugs are used to treat ventricular premature beats, ventricular tachycardia, and ventricular fibrillation and to convert atrial fibrillation to normal rhythm. Side effects include arrhythmias (which can be fatal, particularly in individuals with heart disease), digestive upset, dizziness, light-headedness, tremor, retention of urine, increased intraocular (eye) pressure in individuals with glaucoma, and dry mouth. Examples of sodium channel blockers include disopyramide (Norpace®), flecainide (Tambocor®), lidocaine (Xylocaine®), mexiletine (Mexitil®), moricizine (Ethmozine®), procainamide (Procan®, ProcanSR®), propafenone (Rythmol®), quinidine (Quinidex®), and tocainide (Tonocard®).
  • Beta blockers:

  • Beta blockers slow the heart rate by reducing the speed of the heart's contractions. Beta blockers are used to treat ventricular premature beats, ventricular tachycardia, ventricular fibrillation, and paroxysmal supraventricular tachycardia. They are also used to slow the ventricular rate in people with atrial fibrillation or atrial flutter. Individuals who have asthma and diabetes should not take these drugs. Examples of beta blockers include atenolol (Tenormin®), metoprolol (Lopressor®, Toprol®, Toprol XL®), nadolol (Corgard®), and propranolol (Inderal®).
  • Potassium channel blockers:

  • Potassium channel blockers are used to treat ventricular premature beats, ventricular tachycardia, ventricular fibrillation, atrial fibrillation, and atrial flutter. Because amiodarone (Cordarone®) can be toxic, it is used for long-term treatment only in some people who have serious arrhythmias. Bretylium (Bretylol®) is used only for short-term treatment of life-threatening ventricular tachycardias. Side effect of potassium channel blockers include arrhythmias, scarring in the lungs (pulmonary fibrosis), and low blood pressure. Potassium channel blockers include amiodarone (Cordarone®), bretylium (Bretylol®), and sotalol (Betapace®).
  • Calcium channel blockers:

  • Calcium channel blockers slow the conduction of electrical impulses through the atrioventricular node and are used to slow the ventricular rate in individuals who have atrial fibrillation or atrial flutter and to treat paroxysmal supraventricular tachycardia. Side effects include constipation, diarrhea, low blood pressure, and swollen feet. Calcium channel blockers include diltiazem (Cardizem®, Cardizem CR®) and verapamil (Calan®, Calan SR®).
  • Digoxin:

  • Digoxin (Lanoxin®, Digitek®) slows conduction of electrical impulses through the atrioventricular node. Digoxin is used to decrease the ventricular rate in people who have atrial fibrillation or atrial flutter and to treat paroxysmal supraventricular tachycardia. The drug is given to infants and children younger than 10 years who have Wolff-Parkinson-White syndrome, but older individuals with the syndrome should not take digoxin. Side effects of digoxin include weight loss, nausea, vomiting, and serious arrhythmias; if the dose is too high, xanthopsia (a condition in which objects appear greenish yellow and have a halo around them) may occur. Digoxin was originally isolated from the foxglove plant (Digitalis purpurea).

Electrical

  Electrical Devices
 Cardioversion is a procedure used to treat abnormal heart rhythms (arrhythmias). The most commonly treated arrhythmia is atrial fibrillation. An electrical "shock" is delivered to the heart to restore its rhythm to a normal pattern. The electrical energy can be delivered externally, with electrodes placed on the chest or directly to the heart using paddles on the heart during an open chest surgery. Alternately, the energy can be delivered through the electrodes of a permanently implanted device called a cardioverter-defibrillator.

Hormone

Not recommended:
  DHEA
 Ray Sahelian, MD has reported arrhythmias of different types in individuals using as little as 50mg DHEA or 25mg Pregnenolone. [TLDP Feb 1998, p.119]

Lab Tests/Rule-Outs

  Test for Food Allergies
  Test Thyroid Function
 Atrial fibrillation is 3 times more likely in an elderly person with low TSH. [Family Practice News Mar 15, 1995]

Mineral

  Magnesium
 A magnesium deficiency can produce electrical changes in the heart muscle and thus lead to arrhythmia. Magnesium is commonly given to patients with arrhythmias but is thought to drive potassium into cells, producing lower serum potassium if not enough potassium is available to maintain normal serum levels. When in doubt, it is best to supplement both potassium and magnesium together.

In 22 postmenopausal women it was found that a low magnesium diet caused a significant increase in both supraventricular and supraventricular plus ventricular beats compared to a diet higher in magnesium. [Am J Clin Nutr, 2002;75: pp.550-554]

Nutrient

  TMG (Tri-methyl-glycine) / SAMe
 A four-year clinical evaluation of DMG (or TMG) by Mitchell Pries, MD of Palmdale, California has confirmed Soviet findings. In trials involving the administration of DMG at 125mg bid to over 400 cardiovascular patients, Dr. Pries reported major improvements in several areas including arrhythmias. This dose is low, and a more rapid response may be possible at higher doses.

  CoQ10 (Ubiquin-one/ol)
 Research has shown that orally administered CoQl0 can improve functioning of myocardial tissue, strengthening the heart's contractions and making it beat more strongly (positive inotropic effect) and more regularly (anti-arrhythmia effect). CoQ10 also acts as an antioxidant to control free radicals produced during cardiac interventions (including angioplasty, thrombolysis, and surgery).

  Essential Fatty Acids
 Omega 3 fatty acids may reduce the incidence of arrhythmias during a heart attack. [Japanese Circulation Journal Dec, 1994;58: pp.903-12] One investigation found that people taking fish oil capsules had a 48% reduction in the number of extra heartbeats, but this remains speculative as a separate study did not find this expected link.

Physical Medicine

  Massage
 In cases of supraventricular tachycardia, stimulation of the vagus nerve is a commonly employed technique to help return the heart rate to normal. This can be done in several ways:
  • Perform the Valsalva maneuver (briefly strain or bear down as though having a bowel movement)
  • Using one hand, pinch the nose closed with index finger and thumb, while covering your mouth (to provide resistance) and blow out with vigor
  • Pressing/massaging one side of the neck on the carotid artery. Only press on one side of the neck at a time, not both at once
  • Make yourself gag
All of these techniques serve to stimulate the vagus nerve which slows the heart rate.
 
 


KEY
Weak or unproven link
Strong or generally accepted link
Proven definite or direct link
May do some good
Likely to help
May have adverse consequences







GLOSSARY

Anticoagulant:  A substance that prevents or delays blood clots (coagulation).

Apnea:  Cessation of breathing.

Arrhythmia:  A condition caused by variation in the regular rhythm of the heartbeat. Arrhythmias may cause serious conditions such as shock and congestive heart failure, or even death.

Asymptomatic:  Not showing symptoms.

Biopsy:  Excision of tissue from a living being for diagnosis.

Bradycardia:  Slow heart rate.

Cardiac:  Pertaining to the heart, also, pertaining to the stomach area adjacent to the esophagus.

Chronic:  Usually Chronic illness: Illness extending over a long period of time.

Copper:  An essential mineral that is a component of several important enzymes in the body and is essential to good health. Copper is found in all body tissues. Copper deficiency leads to a variety of abnormalities, including anemia, skeletal defects, degeneration of the nervous system, reproductive failure, pronounced cardiovascular lesions, elevated blood cholesterol, impaired immunity and defects in the pigmentation and structure of hair. Copper is involved in iron incorporation into hemoglobin. It is also involved with vitamin C in the formation of collagen and the proper functioning in central nervous system. More than a dozen enzymes have been found to contain copper. The best studied are superoxide dismutase (SOD), cytochrome C oxidase, catalase, dopamine hydroxylase, uricase, tryptophan dioxygenase, lecithinase and other monoamine and diamine oxidases.

DHEA:  Dehydroepiandrosterone (DHEA) is a steroid produced by the adrenal glands and is the most abundant one found in humans. DHEA may be transformed into testosterone, estrogen or other steroids. It is found in the body as DHEA or in the sulfated form known as DHEA-S. One form is converted into the other as needed.

Ectopic:  Located outside normal position, e.g., location of fetus in pregnancy.

Electrocardiogram:  A test that shows a tracing of the electrical conduction of the heart.

Gram:  (gm): A metric unit of weight, there being approximately 28 grams in one ounce.

Hemochromatosis:  A rare disease in which iron deposits build up throughout the body. Enlarged liver, skin discoloration, diabetes mellitus, and heart failure may occur.

Hormones:  Chemical substances secreted by a variety of body organs that are carried by the bloodstream and usually influence cells some distance from the source of production. Hormones signal certain enzymes to perform their functions and, in this way, regulate such body functions as blood sugar levels, insulin levels, the menstrual cycle, and growth. These can be prescription, over-the-counter, synthetic or natural agents. Examples include adrenal hormones such as corticosteroids and aldosterone; glucagon, growth hormone, insulin, testosterone, estrogens, progestins, progesterone, DHEA, melatonin, and thyroid hormones such as thyroxine and calcitonin.

Magnesium:  An essential mineral. The chief function of magnesium is to activate certain enzymes, especially those related to carbohydrate metabolism. Another role is to maintain the electrical potential across nerve and muscle membranes. It is essential for proper heartbeat and nerve transmission. Magnesium controls many cellular functions. It is involved in protein formation, DNA production and function and in the storage and release of energy in ATP. Magnesium is closely related to calcium and phosphorus in body function. The average adult body contains approximately one ounce of magnesium. It is the fifth mineral in abundance within the body--behind calcium, phosphorus, potassium and sodium. Although about 70 percent of the body's magnesium is contained in the teeth and bones, its most important functions are carried out by the remainder which is present in the cells of the soft tissues and in the fluid surrounding those cells.

Milligram:  (mg): 1/1,000 of a gram by weight.

Pulmonary:  Pertaining to the lungs.

Selenium:  An essential element involved primarily in enzymes that are antioxidants. Three selenium- containing enzymes are antioxidant peroxidases and a fourth selenium-containing enzyme is involved in thyroid hormone production. The prostate contains a selenium-containing protein and semen contains relatively large amounts of selenium. Clinical studies show that selenium is important in lowering the risk of several types of cancers. In combination with Vitamin E, selenium aids the production of antibodies and helps maintain a healthy heart. It also aids in the function of the pancreas, provides elasticity to tissues and helps cells defend themselves against damage from oxidation.

Serum:  The cell-free fluid of the bloodstream. It appears in a test tube after the blood clots and is often used in expressions relating to the levels of certain compounds in the blood stream.

Stroke:  A sudden loss of brain function caused by a blockage or rupture of a blood vessel that supplies the brain, characterized by loss of muscular control, complete or partial loss of sensation or consciousness, dizziness, slurred speech, or other symptoms that vary with the extent and severity of the damage to the brain. The most common manifestation is some degree of paralysis, but small strokes may occur without symptoms. Usually caused by arteriosclerosis, it often results in brain damage.

Tachycardia:  Excessively rapid heart rate.

Thyroid:  Thyroid Gland: An organ with many veins. It is at the front of the neck. It is essential to normal body growth in infancy and childhood. It releases thyroid hormones - iodine-containing compounds that increase the rate of metabolism, affect body temperature, regulate protein, fat, and carbohydrate catabolism in all cells. They keep up growth hormone release, skeletal maturation, and heart rate, force, and output. They promote central nervous system growth, stimulate the making of many enzymes, and are necessary for muscle tone and vigor.

Ventricular Tachycardia:  Excessively rapid heart beat due to uncontrolled ectopic focus in the ventricle.

Zinc:  An essential trace mineral. The functions of zinc are enzymatic. There are over 70 metalloenzymes known to require zinc for their functions. The main biochemicals in which zinc has been found to be necessary include: enzymes and enzymatic function, protein synthesis and carbohydrate metabolism. Zinc is a constituent of insulin and male reproductive fluid. Zinc is necessary for the proper metabolism of alcohol, to get rid of the lactic acid that builds up in working muscles and to transfer it to the lungs. Zinc is involved in the health of the immune system, assists vitamin A utilization and is involved in the formation of bone and teeth.