Panic Attacks in Patients with Supraventricular Tachycardia: Problems of Differential Diagnosis and Impact on Quality of Life

Aim. To study the psychosomatic relationships and quality of life (QOL) of patients with paroxysmal supraventricular tachycardia (SVT) depending on the presence or absence of panic attacks (PA) in comparison with patients with heartbeat against the background of somatoform autonomic dysfunction.Material and methods. The study included patients with SVT and heart attacks due to sinus tachycardia in the context of somatoform autonomic disorder (SAD). All patients were interviewed to identify anxiety and depressive disorders (Hospital Anxiety and Depression Scale [HADS] and Hamilton's Depression Scale), QOL assessment (SF-36 questionnaire), and they were also consulted by a psychiatrist who established the presence or absence of PA. According to a visual analogue scale, in points from 0 to 6, we assessed the general state of our patients' health (0 points corresponded to complete health, and 6 points corresponded to a serious illness) and the effect of heartbeat on well-being (0 points - no arrhythmia, 6 points - arrhythmia «nterferes with life»).Results. The study included 96 patients: 60 with SVT (21 men, 39 women, average age was 51 [33; 61] years) and 36 with heart attacks caused by sinus tachycardia in the framework of somatoform autonomic disorder (10 men, 26 women, average age was 33 [27; 41] years). Panic disorder was diagnosed in the SVT group in 17 patients, accounting for 28.3%. Only 7 patients (41%) could clearly differentiate between SVT and PA attacks. The low sensitivity of the HADS questionnaire in patients with SVT determined the need to consult a psychiatrist for the diagnosis of panic disorders.Conclusion. PA is typical for 28.3% of patients with SVT. The combination of SVT with PA reduces the QOL of patients due to its mental components, including due to the more frequent occurrence of depressive symptoms. Patients with SAD subjectively perceive the heartbeat as a more significant factor affecting health, compared with patients with SVT. Difficulties in the differential diagnosis of PA and SVT paroxysms in real clinical practice often lead to the appointment of the same therapy without taking into account the differences in the genesis of heartbeats.

Supraventricular Tachycardia Ablation and Effects on Anxiety Medications

Background: Patients with true paroxysmal supraventricular tachycardia (SVT) are frequently misdiagnosed with panic or anxiety disorders due to similar symptoms of palpitations, light-headedness, dyspnea, or chest discomfort. Unrecognized SVT can lead to unnecessary management with anxiety medications. Treatment of SVT with catheter ablation may lead to reduction in anxiety medications. Methods: A total of 175 patients underwent successful SVT ablation between January 1, 2010 and December 31, 2020. We examined symptoms at presentation, psychiatric medications prior to SVT ablation, comorbidities, and psychiatric medications at 3 months post-ablation. Results: 15% of patients who underwent successful SVT ablation were being treated with psychiatric medications and were included in the final study population. The most common symptoms were palpitations (80.77%), followed by dizziness (42.31%), and shortness of breath (34.62%). The average number of medications prior to ablation was 1.42 and decreased down to 1.08 at 3 months post-ablation (p = 0.04). The average number of SSRIs, SNRIs, and other anxiolytics were also decreased but were not statistically significant. Conclusion: In patients with anxiety and paroxysmal supraventricular tachycardia, catheter ablation is associated with reduced average number of psychiatric medications.

Adenosine-induced ventricular fibrillation in a patient with supraventricular tachycardia

Adenosine is frequently used for paroxysmal supraventricular tachycardia (PSVT) treatment in the emergency department (ED). Atrial and ventricular pro-arrhythmic effects of adenosine were described in the literature, but ventricular fibrillation (VF) secondary to adenosine administration was rarely reported (with an incidence of < 1%). Reported herein is the first case of a 72-year-old female patient who developed VF hemodynamic collapse after an intravenous administration of adenosine for PSVT treatment. She had no known pre-excitation or accessory pathway, nor any underlying structural heart disease or prolonged QT syndrome. Raising awareness of this potential life-threatening pro-arrhythmic effect of adenosine is important, given its frequent use for PSVT treatment in the ED.

Incidence of Arrhythmias and Their Prognostic Value in Patients With Multiple Myeloma

Background: Arrhythmias are common cardiovascular complications in multiple myeloma (MM) patients and are related to a poor prognosis.Objective: This study aimed to assess the burden of arrhythmias and their prognostic value in patients with MM.Methods: This was a retrospective study of patients with MM between January 2015 and April 2020 at the First Affiliated Hospital of Xi'an Jiaotong University. The incidence of arrhythmia and associated risk factors were evaluated. The relationship between the type of arrhythmia and survival was analyzed.Results: A total of 319 patients with MM were identified, and 48.0% (153/319) had arrhythmias. The most common type of arrhythmia was sinus tachycardia (ST) (15.0%, 48/319), followed by sinus bradycardia (SB) (14.4%, 46/319), premature atrial contractions (PACs) (6.3%, 20/319), conduction disorders (CDs) (6.0%, 19/319), atrial fibrillation (AF) (6.0%, 19/319), premature ventricular contractions (PVCs) (4.4%, 14/319) and paroxysmal supraventricular tachycardia (PSVT) (0.6%, 2/319). The patients with arrhythmias had higher levels of log NT-proBNP and creatinine, greater bortezomib use, and a higher incidence of diabetes than those without arrhythmias (P &lt; 0.05). The all-cause mortality rates of patients without arrhythmias and those with AF, ST, PACs, CDs, SB, and PVCs were 50.6% (84/166), 73.7% (14/19), 60.4% (29/48), 60.0% (12/20), 52.6% (10/19), 34.8% (16/46), and 28.6% (4/14), respectively. In a subgroup analysis of patients experiencing different types of arrhythmias, patients with SB had lower all-cause mortality than patients with AF (P &lt; 0.01). Univariate and multivariate Cox analyses showed that there was a positive statistically significant association between SB and survival (HR: 0.592 [0.352–0.998], P = 0.049) in a subgroup analysis of different arrhythmias.Conclusions: Patients with MM had a heavy arrhythmia burden, and in this study, approximately half of MM patients had arrhythmias. MM patients with SB were associated with lower all-cause mortality than those with AF. SB might be an independent positive factor for prognosis.

A Case Report of Subacute Thyroiditis following mRNA COVID-19 Vaccine

Background. Subacute thyroiditis has been reported after administration of influenza vaccine. We describe a case of a patient who developed subacute thyroiditis after administration of. Moderna mRNA COVID-19 vaccine. Case Presentation. A 42-year-old female, with a past medical history of stage IIIB pT3N1aM0 right adenocarcinoma of colon status, after right hemicolectomy on 01/2020, followed by adjuvant chemotherapy, paroxysmal supraventricular tachycardia, iron deficiency anemia, chemotherapy-induced neuropathy, and lumbar radiculopathy, presented to our clinic with anterior neck pain that started 6 days after the second dose of Moderna mRNA COVID-19 vaccine. She was diagnosed with subacute thyroiditis and treated conservatively with pain medications. Conclusion. Subacute thyroiditis could represent one of the side effects of Moderna mRNA COVID-19 vaccine. Further reports are lacking.

The Rare Case of a COVID-19 Pregnant Patient with Quadruplets and Postpartum Severe Pneumonia. Case Report and Review of the Literature

Background and Objectives: The multiple pregnancies associated with COVID-19 is a new and difficult condition to manage. The prognosis for rapid deterioration after the cesarean delivery is difficult to assess and needs close interdisciplinary follow-up due to pregnancy and postpartum-related changes. Materials and Methods: We report the case of a 37-year-old primigesta primipara patient who was admitted to “Elena Doamna” Clinical Hospital of Obstetrics and Gynecology at 33 weeks and 3 days of gestation with high-grade multiple pregnancies (triplets) for threatened premature birth associated with COVID-19. The patient had a history of surgically corrected atrial septal defect during childhood and currently is known to have paroxysmal supraventricular tachycardia. Tocolysis was ineffective and the decision to perform a cesarean operation was made. The diagnosis was established: primigesta, primipara, at 34 weeks of gestation, high-grade multiple pregnancy with triplets, intact membranes, threatened premature birth, surgically corrected atrial septal defect, paroxysmal supraventricular tachycardia, infection with COVID-19. The patient underwent a cesarean intervention and treatment for COVID-19 pneumonia. The intervention took place at 33 weeks and 4 days of gestation resulting in four newborns with weights between 1400 g and 1820 g and Apgar scores between 6–8. All newborns were transferred to a third-degree Neonatology ICU service due to their prematurity. The fourth newborn was not identified in any of the ultrasounds performed during pregnancy. During the postpartum period, the patient had a fulminant evolution of COVID-19 pneumonia, with rapid deterioration, needing respiratory support and antiviral treatment. Discussions: Managing high-risk obstetrical pregnancies associated with COVID-19 requires a multidisciplinary team consisting of obstetricians, anesthesiologists, neonatologists, and infectious disease doctors. Conclusion: Our case is the first to our knowledge in Romania to present an association of high-grade multiple pregancy with COVID19 moderate form, rapidly evolving postpartum, needing rapid intensive care admission, and specific treatment with Remdesivir, with good post-treatment evolution.

Case Report: Coexistent Wolff-Parkinson-White Syndrome and Brugada Phenocopy in a Patient With Pneumonia and Myocarditis

Background: In recent years, Wolff-Parkinson-White (WPW) syndrome and Brugada electrocardiogram (ECG) patterns have been reported as coexistent in the same patient. In most cases, the two waveforms appeared separately. Here, we described combinations of different waveforms on one ECG, such as the Brugada pattern with delta waves and the Brugada pattern with paroxysmal supraventricular tachycardia (PSVT). Importantly, we recorded an alternate conversion of these combined ECG waveforms, which has not previously been reported in the literature. At the same time, we confirmed that the change in the waveform was related to fever by analyzing Holter data.Case: A 48-year-old male was admitted to our hospital due to palpitations and fever. The patient had a history of a cold 3 days ago. Laboratory examinations showed an elevated neutrophil percentage (85%) and troponin I level (0.86 ng/ml). A chest computed tomography (CT) scan showed inflammation in the right lung. The diagnosis of pneumonia and myocarditis was made. ECG indicated WPW syndrome and the Brugada pattern. We recorded the dynamic changes in this combination of delta waves and Brugada waves with a Holter monitor, and we found the changes would happen when the patient's body temperature rose. The doctors thought that the patient's pulmonary infection led to fever, which caused the changes in waveform. After treatment with antibacterial therapy and supportive care, his body temperature returned to normal. The various laboratory indicators also gradually returned to normal. The doctor recommended that the patient undergo further pre-excitation bypass radiofrequency ablation treatment, but the patient refused and was discharged.Conclusion: Delta waves and Brugada ECG patterns could appear on one ECG at the same time. There were dynamic changes of QRS complex, relating to fever.

Terhességi ritmuszavarok modern terápiás megközelítései

Összefoglaló. A ritmuszavarok előfordulása gyakoribb a terhes nők esetén, mint a nem várandósok körében. A legtöbb esetben terápiás beavatkozás nélkül is kihordható a magzat. Hemodinamikai instabilitás és magzatkárosodáshoz vezető fetalis hypoperfusio jöhet létre, amennyiben tartós, magas kamrai frekvenciával járó epizódok jelentkeznek. Ezekben az esetekben a ritmuszavar megszüntetése indokolttá válhat. Az antiarrhythmiás gyógyszerek korlátozottan és nagy körültekintéssel alkalmazhatók a gyermeket várók körében, így a katéterablatio jelenthet biztonságos és használható alternatívát. Ezen beavatkozásokat hagyományosan röntgensugár segítségével végzik, ez azonban az ionizáló sugárzásnak a magzati fejlődésre gyakorolt hatása miatt magas rizikót jelentene. Több éve elérhető a szív-elektrofiziológiában az ún. zéró fluoroszkópiás ablatio, mely a pitvarfibrilláció kezelésében és más ritmuszavarok esetében egyaránt alkalmazható. A terheseknél alkalmazott eljárást két eseten keresztül mutatjuk be. A röntgensugár használatát, a jelen cikkben bemutatott beavatkozások esetén is, sikerült teljesen kiküszöbölnünk. Az első, 23 hetes gravid páciensnél recidív paroxysmalis supraventricularis tachycardia miatt végeztünk elektrofiziológiai vizsgálatot. E vizsgálat során atrioventricularis nodalis reentry tachycardiát igazoltunk és abláltunk sikerrel. Második esetbemutatásunkban egy anteroseptalis járulékos köteg katéterablatiós megoldását mutatjuk be. A terhesség során jelentkező, az anyára és/vagy magzatára veszélyt jelentő ritmuszavar esetén a háromdimenziós térképező rendszer (szükség esetén intracardialis ultrahangvizsgálattal kiegészítve) biztonságos és hatásos alternatívát jelent, olyan esetekben, ha röntgensugár nem használható. Orv Hetil. 2021; 162(41): 1643–1651. Summary. Arrhythmias are more common in pregnant women than in others. In most cases, the fetus can be delivered without therapeutic intervention. Hemodynamic instability and fetal hypoperfusion leading to fetal harm may occur if persistent episodes of high ventricular rate occur. In these cases, resolution of the arrhythmia may be advised. Antiarrhythmic drugs can be used with limitations and great caution in those expecting a child, so catheter ablation may be a safe and usable alternative. These interventions are traditionally performed using X-ray, however, due to the effect of ionizing radiation on fetal development, this would pose a high risk. Zero-fluoroscopic ablation has been available for several years in cardiac electrophysiology, which can be used both in the treatment of atrial fibrillation and in other arrhythmias. The procedure which we used in pregnant women is presented in two cases. We also managed to completely eliminate the use of X-ray during the interventions presented in this article. In the first case, a 23-week-old gravid patient underwent electrophysiological examination for recurrent paroxysmal supraventricular tachycardia. In the electrophysiological study, atrioventricular nodal reentry tachycardia was confirmed and successfully ablated. In our second case study, we present a catheter ablation for anteroseptal accessory pathway. Three-dimensional mapping system (supplemented with intracardiac ultrasound, if necessary), in the case of significant arrhythmia, is a safe and effective alternative where X-rays, which poses a risk to the mother and/or the fetus, cannot be used during pregnancy. Orv Hetil. 2021; 162(41): 1643–1651.