Inappropriate Sinus Tachycardia,Panic Attacks,or WPW

[ChasD]

I am writing to you to talk to you about the diagnosis of Tachycardia. I have been having Tachycardia attacks for 6 years it will be this December and have been unable to get an exact diagnosis. Here is my story: In December of 93 i had and episode of tachycardia of 180bpm that took me to the emergency room. They said that i was having Supraventricular Tachycardia and that my EKG showed "Wolffe Parkinson Whites Syndrome"- it resolved on its own without medications. They referred me to an Electrophysiologist- I went to my vist and they explained the condition and my options- medications or cardiac ablation. They put me on Tenormin in the mean time til i made my decision on the surgery. Between DEC93 and FEB94 i went to the emergency room on numerous occasions scared and afraid i was going to die with these frightening attacks. I felt like i could not lead a normal life so i decided to have the surgery. In Feb 94 i underwent the surgery of ablation for 2 accessory pathways. After my surgery my doct came in and said he was successful at ablating both pathways but that he didn't think that was my problem because they were so small. I guess he was right because the attacks continued even though my EKG was back to normal. So, we looked into other things it might be: Tilt table study(normal),Echocardiogram(normal),Pheochromocytoma(normal),Thyroid studies(normal). He found everything to be normal and said that i actually had a very healthy heart and that the only other thing he could think of was Panic Attacks--- I'm thinking "After all this". Anyway, from Feb 93 til July 97 I have been in counseling for Panic Attacks with still no resolvement so when i moved back home after my husband getting out of the military i went to seek help from another cardiologist thinking something was missed. I told her my story and did an Ekg,echo,holter monitor, and event monitor and diagnosed me with "Inappropriate Sinus Tachycardia" and gave me my option-medications or Sinus Node Ablation. Well here i go again - another surgery that might not be necessary or even be successful. So from August 97 til now i don't know what to do. How can it be differentiated between these diagnosis. Here is my symtoms: Tachycardia and pounding heart,sweating,tingling of hands,intense nervousness and panicky feeling,upset stomach that lasts anywhere from 5-10 min and then i go back to feeling fine but tired. On a few occaions-probably 10 total it raced for and hour leading me to the ED- i have never had to have meds to stop -it always resolves on its own. Now my cardiologist is saying "Inappropritate Sinus Tachycardia" and "Panic Attacks". How do we know what needs to be treated??? Sorry to be so long but i wanted you to have a true understanding of my frustration with a diagnosis. Please Help- I greatly appreciate your services that you provide.

[Cleveland Clinic, MD]

Dear  ChasD,

Thank you for your question. There are many causes of tachycardia  (fast heart beat) and they can be divided roughly into sinus (originating from the sinus node or heart's natural pacemaker) and non-sinus tachycardias.  Nonsinus tachycardias are either  supraventricular (coming from the upper chambers of the heart) or ventricular (coming from the lower chambers of the heart).  Supraventricular tachycardias include:  paroxysmal supraventricular tachycardia, atrial flutter, atrial fibrillation and AV nodal tachycardia. Ventricular tachycardias are more serious in nature and are due to a rapid depolarization of  the ventricles.  

Sinus tachycardia is defined as a heart rate of greater than 100 beats per minute originating from the sinus node.  Sinus tachycardia is classified as either appropriate or inappropriate.  There are many causes of appropriate sinus tachycardia such as exercise, anxiety, panic attacks, dehydration, deconditioning, volume loss due to bleeding or other loss of body fluids, hyperthyroidism, electrolyte abnormalities and many other conditions.

Inappropriate sinus tachycardia can only be diagnosed when all causes of appropriate sinus tachycardia have been ruled out.  It is not clear what causes inappropriate sinus tachycardia but possible etiologies are an increase in the rate at which the sinus node depolarizes and an increased sensitivity to adrenaline.  Once the diagnosis has been made by ruling out all of the potential causes of appropriate sinus tachycardia  there are several treatment options.  If the symptoms are not overly concerning no treatment needs to be done.  There is no increase in morbidity or mortality in persons with this condition and they can expect to have a normal life-span.  For persons in whom the symptoms are unbearable medications such as beta blockers or calcium channel blockers can be used, usually with good results.  In the rare person unable to tolerate medical treatment catheter ablation (burning) of the sinus node with insertion of a pacemaker or surgical removal of the sinus node have been used in the past.  Newer techniques are being developed using catheter ablation to modify and not destroy the sinus node thus avoiding the need for a pacemaker.   This procedure is still in it's infancy and should only be undertaken at a major medical center after consultation with an electrophysiologist.

[ChasD]

I don't understand why 6 years ago they diagnosed me with "Wolffe Parkinson Whites Syndrome" and then after i  went through the ablation they said that i acually didn't have the syndrome,and it wasn't causing my problems. They said that i had two acessory pathways-i remember them saying something about one being on the front and one on the back,something about one being a little more risky to ablate because it was near something??? but it was successful. Ok,so i had the pathways,they ablated them,and then they tell me even before i have any more tachycardia attacks that wasn't my problem. I don't understand and it leaves me very confused-I was 20 at the time and maybe i just didn't understand what they were telling me. Could you please explain. Here are my questions:1)If i had 2 accessory pathways does that give me the diagnosis of WPW? 2)How could they tell after ablating my pathways that was not my problem even before i had another tachycardia attack? 3)What do i say on my medical history that i had WPW or not? 4)Since i'm still having tachycardia attacks could the WPW or accessory pathways have returned? And, would an EKG always show the pathways when they come back because i have had EKG's since my surgery all being normal even though i'm still having the tachycardia.      

Thank you so much for your time that you take to answer the
questions on this board so thouroughly. This is a wonderful site to have;I only wish i had found it much earlier to know that i'm not alone with these heart problems at age 26.

[ChasD]

There were a few more questions i forgot to ask in regard to my most recent 2 diagnosis a two years ago "Inappropriate Sinus Tachycardia" and "Panic Attacks". Here are my questions: 1)The doctor that diagnosed my WPW,ablated the pathways,and then told me that wasn't my probem- Why did he not mention IST? I wasn't diagnosed til 3 years later by another cardiologist. 2)What is your opininon on my heartrates 160-180's can this be a panic attack with the heartrate this high or do you think it sounds more heart related? 3)Are IST and Panic Attack symtoms similar- could i be having both? 4)Are these common symtoms of IST causing tachycardia? phone rings and startles,after eating a heavy meal or one filled with alot of carbs or sugars,alot of stress,heartrate increases quickly during exercise and comes down slower,after drinking alcohol,wake up out of sound sleep and heart starts to race,normal activities causes tachycardia like climbing stairs or sweeping,or just pure out of the blue be sitting doing nothing and it starts racing 5)Lastly, in your opinion what are some good medications to try if i don't have an exact diagnosis? Will it hurt me to take meds if i'm only having tachycardia attacks a few times a month-what i mean is will it hurt me during the times i'm at a normal rate?
Thanks Again

[Cleveland Clinic, MD]

Could you please explain. Here are my
     questions:1)If i had 2 accessory pathways does that give me the diagnosis of WPW?
A: The problem here is one of termnology.  WPW is a type of accessory pathway but not all accessory pathways are WPW.  Yours apparently was not.


2)How could they tell after
     ablating my pathways that was not my problem even before i had another tachycardia attack?
A: They really can't.  All they can tell is at that time all accessory pathways have been ablated.


3)What do i say on
     my medical history that i had WPW or not?
A: Say that you had an accessory pathway.


4)Since i'm still having tachycardia attacks could the WPW or
     accessory pathways have returned?
A: It is possible but unlikely that the pathway was not totally ablated and is still causing problems.

[Cleveland Clinic, MD]

1)The doctor that diagnosed my
     WPW,ablated the pathways,and then told me that wasn't my probem- Why did he not mention IST? I wasn't
     diagnosed til 3 years later by another cardiologist.
A: ? maybe you didn't have it at that time.

2)What is your opininon on my heartrates 160-180's can this
     be a panic attack with the heartrate this high or do you think it sounds more heart related?
A: It still could be a panic attack but I wouldn't make that diagnosis until heart related issues were excluded, especially given your history.

3)Are IST and Panic
     Attack symtoms similar- could i be having both?
A: Unfortunately yes.


4)Are these common symtoms of IST causing tachycardia?
     phone rings and startles,after eating a heavy meal or one filled with alot of carbs or sugars,alot of stress,heartrate
     increases quickly during exercise and comes down slower,after drinking alcohol,wake up out of sound sleep and
     heart starts to race,normal activities causes tachycardia like climbing stairs or sweeping,or just pure out of the blue
     be sitting doing nothing and it starts racing
A: IST has a wide spectrum of triggers/causes.  These are possible.

5)Lastly, in your opinion what are some good medications to try if i
     don't have an exact diagnosis? Will it hurt me to take meds if i'm only having tachycardia attacks a few times a
     month-what i mean is will it hurt me during the times i'm at a normal rate?
A: No, it won't hurt you.  Usually beta-blockers are the first drugs tried for these type of episodes.