A 45-year-old woman who lives alone in a rural area experiences sudden onset of palpitations associated with dyspnea, profuse sweating, paresthesia in both hands, and a rapid pounding sensation in her neck after an argument with a neighbor. She has had similar symptoms for the past several years that usually last <5 min. During one episode, her symptoms resolved after bearing down. Approximately 6 months ago, an episode did not resolve on its own and required her to drive to the local emergency department (ED), approximately 20 min away, where she was found to be in sinus tachycardia. She was advised to follow up with her primary care provider (PCP). At her recent yearly visit with her PCP, she reported these symptoms, noting that her episodes often occur in association with emotional distress and worsen her anxiety. She was prescribed sertraline to treat a panic disorder.
During her current episode, her home blood pressure (BP) device indicates that her BP is 105/76 mm Hg and heart rate (HR) is 145 bpm. She repeatedly tries Valsalva maneuvers, including lying down and raising her legs after straining, with no success. She prepares a large basin full of ice water and submerges her face in it. She shivers but her symptoms persist. She becomes lightheaded and has a sense of impending doom. Frustrated and increasingly anxious, she calls 911, concerned that this episode may be life-threatening.
The correct answer is: C. A definitive diagnosis cannot be determined.
Palpitations are the most frequent symptom in individuals with PSVT, but up to 90% of people with panic disorder experience palpitations. Furthermore, anxiety disorders are present in approximately 25% of patients with PSVT. Therefore, the clinical presentation and associated symptoms of PSVT can overlap with those of anxiety disorders. This overlap may create a diagnostic challenge, especially in cases when an electrocardiogram (ECG) has not been recorded during the attack. A significant proportion of patients with PSVT are misdiagnosed with an anxiety or panic disorder (>30-40%). This incorrect diagnosis is much more common in women than men (65% vs. 32% in one study). Ascribing a psychiatric diagnosis to such symptoms may result in a correct diagnosis of PSVT being unrecognized for many years. Notably, women with PSVT are often referred to electrophysiology (EP) much later in their clinical course than are men.
Vagal maneuvers transiently increase the effective refractory period of the AVN and may interrupt the electrical circuit in an AVN-dependent tachycardia such as atrioventricular nodal re-entrant tachycardia (AVNRT) or atrioventricular reciprocating tachycardia. Current American College of Cardiology (ACC) guidelines recommend vagal maneuvers as first-line therapy for hemodynamically stable PSVT. The efficacy of standard vagal maneuvers and carotid sinus massage for acute termination of PSVT is inconsistent and relatively low, ranging from approximately 5% to 20%. A modified vagal maneuver, which involves supine positioning with leg raising following the strain phase, recently has been advocated as a superior first-line approach for treatment of PSVT, with a greater-than-twofold effectiveness compared with that of standard vagal maneuvers. However, the efficacy of optimally applied vagal maneuvers for acute PSVT termination remains under approximately 40-50%. A patient's clinical history of vagal maneuvers failing to terminate an episode of sustained palpitations lacks sufficient sensitivity and predictive accuracy to sufficiently rule out AVN-dependent PSVT as the cause of their symptoms.
POTS is a type of dysautonomia in which orthostatic intolerance manifests as episodes of persistent tachycardia (increase in HR of >30 bpm) while standing or sitting in the absence of a significant decline in BP. If upright posture does not clearly exacerbate symptoms and HR, then a diagnosis of POTS should not be made.
This patient case quiz is part of the larger A Modern Look at Paroxysmal Supraventricular Tachycardia (PSVT) grant‑supported initiative, funded by Milestone Pharma. To access additional educational activities on Paroxysmal Supraventricular Tachycardia, please visit the PSVT learning page linked here.
References
- Peng G, Zei PC. Diagnosis and management of paroxysmal supraventricular tachycardia. JAMA. 2024;331(7):601-610. doi:10.1001/jama.2024.0076
- Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2016;67(13):e27-e115. doi:10.1016/j.jacc.2015.08.856
- Frommeyer G, Eckardt L, Breithardt G. Panic attacks and supraventricular tachycardias: the chicken or the egg?. Neth Heart J. 2013;21(2):74-77. doi:10.1007/s12471-012-0350-2
- Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Unrecognized paroxysmal supraventricular tachycardia. Potential for misdiagnosis as panic disorder. Arch Intern Med. 1997;157(5):537-543.
- Carnlöf C, Iwarzon M, Jensen-Urstad M, Gadler F, Insulander P. Women with PSVT are often misdiagnosed, referred later than men, and have more symptoms after ablation. Scand Cardiovasc J. 2017;51(6):299-307. doi:10.1080/14017431.2017.1385837
- Lan Q, Han B, Wu F, Peng Y, Zhang Z. Modified Valsalva maneuver for treatment of supraventricular tachycardias: a meta-analysis. Am J Emerg Med. 2021;50:507-512. doi:10.1016/j.ajem.2021.08.067
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