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: E. Discharge her with a symptom-activated ECG event monitor with EP follow-up advised.
The correct diagnosis in this patient is uncertain. Simply assuming that her recurrent attacks are due to her panic disorder diagnosis may delay correct diagnosis and optimal management for an indefinite period. Attempting to provide better symptom–rhythm correlation by obtaining an ECG recording during a similar future episode is the best next management step. A patient-activated ECG event monitor or a patch monitor, usually of 14-30 days’ duration, would be the best next step for her. Alternatively, a direct-to-consumer wearable device may be a good long-term solution for providing a recording during an episode. Her report of regular, rapid pounding sensations in the neck during an attack and an episode lasting >5 min combined are a strong indicator and increase the likelihood of a diagnosis of PSVT due to AVNRT. This clinical presentation suggests that earlier referral of this patient to an electrophysiologist may be appropriate. Of note, among those with supraventricular tachycardia (SVT), witnessed neck pulsations during an episode are specific for the presence of typical AVNRT (specificity 97%; positive predictive value 83%).
A 24-hour Holter monitor lacks sufficient sensitivity to rule out PSVT because the duration of the recording may not be long enough to catch and record an ECG during a symptomatic episode. Prescribing etripamil (an intranasally administered, nondihydropyridine L-type calcium channel blocker [CCB]) in the ED for future at-home management of PSVT may be a reasonable option. However, in the pivotal NODE-301 (Efficacy and Safety of Etripamil for Termination of Spontaneous PSVT) study (also known as the RAPID study), which led to Food and Drug Administration (FDA) approval, eligible patients had to have a history of PSVT with sustained (≥20 min) symptomatic episodes documented by ECG. A subsequent real-world study of etripamil, the NODE-303 (Open-Label, Phase 3 Trial of Etripamil for SVT), did not require ECG documentation of prior PSVT for study enrollment but only a diagnosis of PSVT by a medical professional and a patient report of at least one previous episode of symptomatic PSVT. The NODE-303 investigators did not exclude patients with a history of atrial fibrillation/flutter or sinus tachycardia.
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
- Thavendiranathan P, Bagai A, Khoo C, Dorian P, Choudhry NK. Does this patient with palpitations have a cardiac arrhythmia?. JAMA. 2009;302(19):2135-2143. doi:10.1001/jama.2009.1673
- Sakhuja R, Smith LM, Tseng ZH, et al. Test characteristics of neck fullness and witnessed neck pulsations in the diagnosis of typical AV nodal reentrant tachycardia. Clin Cardiol. 2009;32(8):E13-E18. doi:10.1002/clc.20455
- Stambler BS, Camm AJ, Alings M, et al. Self-administered intranasal etripamil using a symptom-prompted, repeat-dose regimen for atrioventricular-nodal-dependent supraventricular tachycardia (RAPID): a multicentre, randomised trial. Lancet. 2023;402(10396):118-128. doi:10.1016/S0140-6736(23)00776-6
- Ip JE, Coutu B, Ip JH, et al. Etripamil nasal spray for recurrent paroxysmal supraventricular tachycardia conversion: results from the NODE-303 open-label study. J Cardiovasc Electrophysiol. 2025;36(11):2990-3003. doi:10.1111/jce.70086
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