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Re: PSVT or Panic Attack

Posted By CCF CARDIO MD - CRC on November 24, 1998 at 13:09:05:

In Reply to: Re: PSVT or Panic Attack posted by Denise on November 24, 1998 at 11:55:03:

: : I am a 52 year old female and have recently been diagnosed with PSVT after a visit to the ER with a heart rate of 210bpm. Since the age of 28 I have experienced what I thought were panic attacks and have been on meds for anxiety since 1993. When I was diagnosed with PSVT I found out that this condition was commonly misdiagnosed as panic disorder. The symptoms for both seem to be the same. For example: palpations, rapid pulse, anxiety(feeling of impending doom), shortness of breath and chest tightness.
Now I am left wondering just how much of what I have experienced in the past years as panic attacks have actually been the PSVT.
: : My question is: can you experience any one single symptom alone such as shortness of breath or even a rapid pulse that is lower in range(110-120bpm) than the typical 150bpm and up, and still be the result of the PSVT.
I am taking toprol for the tachycardia but It makes me sleepy and sluggish and I still have an occasional daily flutter. I have seen a EP specialist and am considering RV ablation. I admit that I am terrified of the prospects of a 2-6 hour procedure. I am open to any suggestions or recommendations. In recent years what I believed to be, the panic/anxiety disorder, has become more disrupted. If I thought that even 25% of the so-called panic attacks were actually a PSVT episode I would have the ablation done tomorrow.

: Hi,
I am a doctor by no means, but will give my personal experience.
I started having PSVT last September.  I went into the E.R. and with a heart rate of 180 and when they hooked me up to the EKG, my rate was 130 because the nurse showed me a maneuver to get out of the arrhythmia before the EKG.  They diagnosed it as SVT.  They just didn't have the location of the SVT.
Well, needless to say, my electrophysioligst suggested I see a Neurologist because of the numbness in my head I would experience before some of my attacks.  One of the first things the Neurologist said "It is common for women your age to have panic attacks".  Well, I knew from the very beginning I would just let her do whatever testing she wanted to make sure nothing neurologically was wrong, but other than that, nothing else.
I am not a stressed person and hate being told stress this and stress that.  What stresses you is the fact you are having these things and people are telling you it is stress, but you know differently.  You saved a lot of time by having the E.R. tell you about the PSVT (as have I).
I don't know you, so I have no idea on your history of stress.  What would happen to me during these attacks is:
: chest pain (sometimes)
: numbness or tingling in face (sometimes)
: abrupt increase in heart rate (usually 180)
: tremors afterward
I had the ablation done on October 12 so I could be medication free.  The procedure lasted 2 1/2 hours for me.  Before that, I had not been sedated since I was 8 years old (33 now), so I can relate to not wanting to go through this procedure.  Only your electrophysiologist can tell you whether you are a good candidate for this procedure.  It is all over before you know it.  Does the electrophysiologist think you are having anxiety/panic attacks or do s/he think this is all related to the PSVT?
I've never experienced an anxiety/panic attack (that I know of), only these PSVTs and can tell you, they are scary and NO FUN!  Go on what your electrophysiologist suggests because s/he knows your history.  I went for it because there was no way I wanted to have to deal with that problem all my life!  With the advances in medicine/technology the way it is nowadays, the risks are very low for a "normal" person.  As I stated before, I'm not a doctor and you should decide with your electrophysiologist your best approach to dealing with this. If s/he thinks ablation would be the best for you, GO FOR IT, you are young yet!  I have an excellent electrophysiologist with a high success rate.  I'm sure the ablation was successful for me.  I have other things beside the PSVT, (i.e. adrenalin problem) so... My cardiologist referred me to the electrophysiologist, so I knew I was in good hands.  Don't be afraid to do research on the electrophysiologist doing your ablation. You definitely want one who has performed a lot of ablations with a high success rate.  If you are near the CCF, go there!  Do some homework, it never hurts!
I'm sure you will get an excellent answer from the CCF.  You are not alone out there!  It is hard for the doctor if they can't get the arrhythmia recorded because the PSVT is so close to anxiety/panic attacks.
Good luck,
Dear Denise,
Thank you for sharing your experience.  Have you had any additional symptoms since your ablation?
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.

Hi Dr. CRC,
Thanks for asking!  Unfortunately, I "think" I still have a PSVT problem.  I am back to wearing an event-monitor for 1 month (have had it for over 2 weeks now).  After my ablation, I was put on 25 mg of Tenormin because of my hypersensitivity adrenergic (they call it Sinus Tachycardia for an unknown reason).  My heart rate before my ablation was 62 bpm, after the ablation, it wouldn't go below 84.
I went to see my regular cardiologist (he and electrophysiologist are two separate people) and he saw my resting heart rate at 106 and said he wanted to increase my Tenormin level to 50 mg, so he did.  This was two weeks ago.  Well, needless to say, I've had a couple of these attacks (on the 25 mg of Tenormin) at 3:00 or 4:00 in the morning.  Because of the increased dosage of Tenormin, I am in the process of getting "weaned" off the Tenormin.  Today is actually my last day and I will be med free to try and record the arrhythmia.
The electrophysiologist said I am the one who has had the symptoms all along before the arrhythmia, so I am the one who can tell best if it is the same thing as before my ablation.  As I stated, I will find out in a few days if it is indeeed the same thing.  I was diagnosed in Sept 97 with SVT when I went into the E.R. for the first time not knowing what was going on (heart rate 180, b/p 180/105).  I was petrified because I never experienced such a thing out of the blue.
The electrophysiologist ordered the event-monitor before the ablation to try to see what the arrhythmia looked like.  On the event-monitor, it would show up as Sinus Tachycardia I guess.  He was suspicious because my heart rate would abruptly increase (i.e. 62 to 150) or at least take huge jumps in the rate.  He said if it was an adrenaline problem at that time, the heart rate would increase gradually to a higher point.
Well, I went for the EPS with possible ablation and he ended up ablation for Paroxysmal Atrial Tachycaria (Sinus Node Reentry).  My heart rate was 150-180 for them to see this arrhythmia.  I started having what I think is the same arrhythmia a week later.  Needless to say, I was very disappointed and still am.
I was told from the very beginning they may not find the SVT or if they ablate and it recurs, a second ablation could possibly be needed.  I knew this from the beginning and have accepted that.  I may add that I was ablated by an electrophysiologist that is well renowned for his work and have been VERY happy with him.  I have to decide after I have the arrhtyhmia (if indeed it is the same) whether I want to go through another ablation.  That was a difficult decision because I still have the unknown Sinus Tachycardia problem, so I will have to take the Tenormin anyway.
I am going off the Tenormin to see what the ablation has truly done for me.  I have accepted the fact I will have to take the beta-blocker indefinitely.  This was a little hard for me to accept because the reason for the ablation was to be med free.  It obviously didn't turn out that way.  I have had subacute thyroiditis in the past two years where I've been between hyper and hypothyroid.  I also have MVP with MR.  I have been diagnosed with Hashimotos too (which comes into play with the thyroid).  I realize I am a little more complex than maybe the normal PSVT person.
I have never been one to run to the doctor at the drop of the hat, so this has definitely not been a pleasant experience for me.  Well, I don't imagine it is for anyone, but in particular not me!  I have my annual exams, but other than that, I would just assume stay away from the doc (no offense).
Whenever I have these arrhythmias, I can bring myself right out of them by the Valsalva maneuver.  The arrhtyhmia itself isn't the scary part.  The really scary part is not knowing when or if they will happen and having the associated symptoms before the arrhythmia itself (i.e. lightheaded, squeezing chest pain, difficulty breathing).  These all happen within a matter of a minute or so and boom the heart rate jumps to 170 or 180.
As for my Sinus Tachycardia problem, I have a problem with the high heart rate in the morning (115 to 120 when standing up).  I will get to about 130-140 while takikng a shower.  Going up about 30 stairs will send it to maybe 160, thus the Tenormin.  I really wished I could get down to the root cause of the Sinus Tachycardia, but was told it is unknown.
Well, that is my story.  I don't think I left anything out.  Thanks for asking, that was quite nice of you.
Dear  Denise,
Thanks for the complete story.  I have enclosed some information on sinus tachycardia that you may find interesting.  It sounds like you are receiving excellent care at your institution.  Good Luck.
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.
Below are some journal articles that address this topic in depth.  Your local medical library should be able to help you find copies.
Review Articles:
Krahn AD.  Yee R.  Klein GJ.  Morillo C.  Inappropriate sinus tachycardia: evaluation and therapy. Journal of Cardiovascular Electrophysiology.  6(12):1124-8, 1995 Dec.
Inappropriate sinus tachycardia is an ill-defined clinical syndrome characterized by an increased resting heart rate accompanied by an exaggerated response to exercise or stress. It is not associated with underlying structural heart disease. The mechanism may involve a primary abnormality of the sinus node demonstrating enhanced automaticity or, alternatively, a primary autonomic disturbance with increase sympathetic activity and enhanced sinus node beta-adrenergic sensitivity. The diagnosis of inappropriate sinus tachycardia is one of exclusion. It is most common in young females, with a disproportionate number employed in the health care field. Autonomic and electrophysiologic testing may be required in selected individuals to clarify the mechanism and rule out sinus node reentry or right atrial tachycardia. Therapy of inappropriate sinus tachycardia is empiric. Pharmacologic approaches include beta blockers or verapamil. Radiofrequency catheter ablation of the superior portion of the sinus node shows promise as a useful alternative in patients with refractory symptoms.

Sims JM.  Miracle V.  Sinus tachycardia. Nursing.  26(6):49, 1996 Jun.

Articles Concerning Catheter Treatment Options.
Lee RJ.  Kalman JM.  Fitzpatrick AP.  Epstein LM.  Fisher WG.  Olgin JE.  Lesh MD.  Scheinman MM. Radiofrequency catheter modification of the sinus node for "inappropriate" sinus tachycardia. Circulation.  92(10):2919-28, 1995 Nov 15.
BACKGROUND: Radiofrequency catheter ablation is the treatment of choice for patients with paroxysmal supraventricular tachycardias refractory to medical therapy. However, in symptomatic patients with inappropriate sinus tachycardia resistant to drug therapy, catheter ablation of the His' bundle with permanent pacemaker insertion is currently applied. We evaluated the safety and efficacy of radiofrequency modification of the sinus node as alternative therapy for patients with inappropriate sinus tachycardia. METHODS AND RESULTS: Sixteen patients with disabling episodes of inappropriate sinus tachycardia refractory to drug therapy (4.2 +/- 0.3 drug trials) underwent either total sinus node ablation or sinus node modification. The region of the sinus node was identified as the region of earliest atrial activation in sinus rhythm during electrophysiological study. This region was further defined by use of intracardiac echocardiography (ICE) in 9 patients, in whom it was found that an ablation catheter could be guided reliably and maintained on the crista terminalis. Radiofrequency energy was delivered during tachycardia between either a standard 4-mm or custom 10-mm thermistor-imbedded catheter tip and a skin patch. Total sinus node ablation was performed successfully in all 4 patients in whom it was attempted and was characterized by a junctional escape rhythm. Sinus node modification was successfully achieved in all 12 patients in whom it was attempted and was characterized by a 25% reduction in the sinus heart rate. For the group as a whole, exercise stress testing after ablation revealed a gradual chronotropic response, with a significant reduction in maximal heart rate (132.8 +/- 6.5 versus 179.5 +/- 3.6 beats per minute [bpm]; P < .001) without evidence of an exaggerated heart rate response to a light workload (103.0 +/- 4.1 versus 139.5 +/- 3.5 bpm; P < .001). Twenty-four-hour ambulatory ECG monitoring revealed a significant decrease in maximal heart rate and mean heart rate after ablation (167.2 +/- 2.6 versus 96.7 +/- 5.0 bpm, P < .001, and 125.6 +/- 5.0 versus 54.1 +/- 5.3 bpm, P < .001, respectively). There was a significant decrease in the number of applications of radiofrequency energy required in patients undergoing modification of the sinus node when guided by ICE compared with fluoroscopy alone (3.6 +/- 0.8 versus 10.4 +/- 2.1; P < .01) as well as a decrease in fluoroscopy time (33.0 +/- 9.5 versus 58.5 +/- 8.4 minutes). After a mean follow-up period of 20.5 +/- 0.3 months, there were no recurrences of inappropriate sinus tachycardia in patients who underwent a total sinus node ablation. However, 2 patients who had a total sinus node ablation subsequently required permanent pacing because of symptomatic pauses, and 1 patient developed an ectopic atrial tachycardia. After a mean follow-up of 7.1 +/- 1.7 months, there were two recurrences of inappropriate sinus tachycardia in patients who underwent sinus node modification. However, no significant bradycardia or pauses were observed. Complications encountered during the study included 1 patient who developed transient right diaphragmatic paralysis and another patient who developed transient superior vena cava syndrome. CONCLUSIONS: Sinus node modification is feasible in humans and should be considered as an alternative to complete atrioventricular junctional ablation for patients with disabling inappropriate sinus tachycardia refractory to medical management. Sinus node modification may be aided by ICE.
Jayaprakash S.  Sparks PB.  Vohra J.  Inappropriate sinus tachycardia (IST): management by radiofrequency modification of sinus node.  Australian & New Zealand Journal of Medicine.  27(4):391-7, 1997 Aug.
BACKGROUND: Inappropriate sinus tachycardia (IST) is a rare form of supraventricular arrhythmia. It can cause disabling symptoms and may be refractory to medical treatment. In symptomatic drug refractory patients, sinus node excision or total ablation of the sinus node with permanent pacemaker implantation was the only therapeutic option. Recently, radiofrequency (RF) modification of the sinus node has been reported to be an effective treatment for this condition. AIM: To present our experience with sinus node modification using RF energy in the management of IST. METHODS: Between 1989 to 1996 three patients (two females and one male), aged 28-36 years were diagnosed with symptomatic IST. All had failed multiple drugs and hence underwent sinus node modification using RF. In the first two patients, the site of RF application was guided by anatomical landmarks using fluoroscopy to localise the presumed most superior portion of the crista terminalis and also the earliest site of atrial activation. In the third patient, a 20 pole electrode catheter was used to map the crista terminalis and guide the ablation. Success was defined by 20-30% reduction in the heart rate with normal atrial activation sequence after ablation. RESULTS: The three patients described here had IST by clinical, electrocardiographic and electrophysiological criteria and were refractory to multiple antiarrhythmic drugs. The number of RF applications were 11, 15, and three applied at the site of earliest atrial activation for the control of heart rates. Patient 3 had a early recurrence at one month and underwent repeat sinus node modification (five RF applications). All three patients who underwent RF modification of the sinus node had a successful outcome. The procedure was uncomplicated and the patients remain asymptomatic during follow up (20, 12 and three months) with satisfactory control of heart rate, although one patient requires atenolol which was previously ineffective. CONCLUSIONS: RF modification of the sinus node is feasible and effective for IST, and should be the treatment of choice in patients refractory to medical therapy.
Surgical treatment  (Only as a last resort)
Esmailzadeh B.  Bernat R.  Winkler K.  Meybehm M.  Pfeiffer D.  Kirchhoff PG.  Surgical excision of the sinus node in a patient with inappropriate sinus tachycardia.  Journal of Thoracic & Cardiovascular Surgery.  114(5):861-4, 1997 Nov.
Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.

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