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Re: Sino Ventricular Tachycardia?

Posted By Jamie  on January 11, 1999 at 13:57:07:

In Reply to: Sino Ventricular Tachycardia? posted by CCF CARDIO MD - CRC on January 11, 1999 at 09:50:47:

: Hi, my name is Jamie and I am 18 years old and was recently diagnosed with
: SVT (Sino ventricular tachycardia)  In August on 98 I began having what I
: call "episodes."  I started having an increased awareness of my heart beat,
: with very strong palpitations.  I have clocked my heart rate at 160 bpm at
: rest.  I visited my GP where she did a thyroid test and checked my BP and
: did an EKG.  Everything looked good.  She told me to cough hard, put my
: head in cold water, gag, or even vomit to see if that would get my heart
: back on track. I tried all of those suggestions but none of them seemed to
: work.   I went from having these episodes from about 3 times a month to
: recently having them about 2 or 3 times a day.  My heart rate while having
: these episode is usually in the 100-120 bpm range.  I have recently passed
: out twice, one in the shower, and once while driving.  At times I feel
: nauseous, usually before or after I pass out, and very light headed.  I
: went back to my doctor where she order a 24 Holter monitor and an
: echocardiogram.  While on the Holter monitor I did not experience one of
: my episodes.  I just had the echo this last Wednesday.  My doctor has also
: prescribed a beta-blocker, Atenolol.  What are the effects of this drug,
: starting it at such a young age?  My doctor said that if I start taking
: this medication that there may be side effects and that I may have to take
:  it for a very long time, maybe even for life.  Is this safe?  Since, my
: appointment, I have experienced several episodes, some lasting 10 minutes,
:  others lasting 2 hours before I go to bed until I fall asleep. All of the
:  episodes leave me very breathless.  I feel that I have to breathe harder
: and deeper to get enough air.  Most of my episodes occur while relaxing,
: watching TV, laying in bed, or limited housework.  In your professional
: opinion, does this sound like Sino ventricular tachycardia or a different
: type of tachycardia.  I know that it is just your opinion and to consult
: my physician!  What are the effects if this is left untreated?  (I have so
:  many questions)  I have completely removed caffeine from my diet for 6
: months, no decongestant pills, no pop, chocolate.  At this time I am not
: going through what I believe to be a stressful time.  So what are the
: other caused of Tachycardia.  Are there other options besides medication?
: Maybe, exercise, or something else?  
Well, I know that I have a lot of questions.  At this time, any
: information from anybody would be greatly appreciated.  
Thank you
: Jamie  
Hi Jamie,
This is what Dr. CRC (great source of info) from this heart forum attached to a question of mine when I was first diagnosed with Supraventricular Tachycardia (SVT).  I find it very informative.
Denise O.
Here is what Dr. CRC attaches:
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. In addition PVC's may cause the
symptoms you are describing. The best way to diagnosis these is to keep a record of episodes during the period of time
of the Holter monitor. This way symptoms can be seen to correlate with specific heart rhythms.
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
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.
Dear Jamie,
Thank you for your question.  The information above is a good overview of causes of tachycardia. As you can see there are many different causes and it sometimes takes a bit of detective work to find the source. Your doctor may want to order a longer heart recording time called a "loop monitor" which can be worn for several weeks. The type of doctor that specializes in this area is called an electrophysiologist.  However, all cardiologists are also trained in this area and your doctor may be able to help you.  Exercise does not help this condition specifically but will help in your overall health and well-being. As far as specific medicine recommendation we always recommend following the advise of your local doctor.
Good luck.

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.

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