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Clinical presentation of paroxysmal supraventricular tachycardia: evaluation of usual and unusual symptoms

Yetkin, Ertana; Ozturk, Selcukb; Cuglan, Bilalc; Turhan, Hasana

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Cardiovascular Endocrinology & Metabolism: December 2020 - Volume 9 - Issue 4 - p 153-158
doi: 10.1097/XCE.0000000000000208
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Abstract

Introduction

Palpitation, by definition unpleasant awareness of regular or irregular or forceful or fast beating of the heart, is one of the most common complaints of patients in outpatient clinics or emergency departments. Feeling of palpitation might have arisen from wide spectrum of arrhythmia ranging from simple atrial or ventricular ectopic beats to various types of supraventricular and ventricular arrhythmias. Among those arrhythmias, paroxysmal supraventricular tachycardia (PSVT) refers to a rhythm disorder originating above the His bundle, which typically causes heart rates in excess of 150 per minute with regular and narrow QRS complex. The electrophysiological substrate of PSVT may express itself in different pathophysiological pathways such as atrioventricular nodal reentrant tachycardia (AVNRT), atrioventricular reentrant tachycardia (AVRT), or atrial tachycardia (AT) in a paradoxical manner [1–4].

However, the clinical presentation of PSVT may vary from asymptomatic occurrence or mild perception of palpitation to severe chest pain or syncope. This variation is the most challenging issue in the diagnostic evaluation of rhythm disturbances and PSVT as well [2,4]. Unfortunately, not too much effort has been paid for the symptoms of PSVT possibly due to tachycardia documented approaches of cardiac electrophysiologists. Accordingly, in this study, we aimed to evaluate the symptoms during and after the tachycardia attack or index event in patients who underwent electrophysiological study (EPS) and ablation procedure.

Methods

Study population

This retrospective study included 100 consecutive patients who underwent EPS and ablation procedures due to SVT. Structural heart disease, moderate/severe valvular pathology, systemic pathologies such as connective tissue disease and chronic obstructive lung disease, history of pacemaker implantation was defined as exclusion criteria. In addition, medically managed patients and patients with unsuccessful ablation procedures were not included in the study. Patients’ demographical and clinical parameters were recorded from the hospital database. The local ethics committee of the hospital approved the study protocol, and the study was performed according to the Helsinki Declaration.

All patients underwent electrocardiographic and echocardiographic examination. Twenty-four-hour ambulatory electrocardiography (ECG) monitoring was performed in selected patients depending on the clinical preference of cardiologist. Routine biochemical and hematological analyses were performed in all patients. Thyroid function tests, including free T3, free T4, and TSH, were shown to be within normal range in patients who were being followed-up for thyroid diseases and in those suspected of thyroidal diseases. The main presenting symptoms and accompanying symptoms during the SVT attacks or index events were questioned systematically and recorded in all patients. The main presenting symptoms were defined as palpitation, chest pain, dyspnea, lightheadedness or dizziness, syncope, and sweating. Presence of polyuria, fatigue, and lightheadedness was also questioned after the termination of SVT attack or index event. Polyuria was defined as unusually frequent and more than one, urination within following 1–3 hours after the index event. Any other symptoms, unusual events, and discomfort mentioned by the patients were also recorded as accompanying symptoms.

Electrophysiological study

EPS was performed in the fasted state, at least 5 half-lives after discontinuation of antiarrhythmic medications. Two quadripolar catheters were introduced into the right ventricular apex (4F) and right atrium (6F) via the right femoral vein; the latter was progressed toward the area of the bundle of His during the study for baseline recording and during tachycardia; a third catheter was placed in the coronary sinus when necessary. When an AVNRT, AVRT, and AT were induced, subsequent ablation procedures were performed. Successful ablation was defined as the absence of re-inducibility of the native tachycardia, disappearance of dual AV node physiology or the loss of the delta wave in AVRT. Subsequently, further electrophysiological testing for additional tachycardias, which could potentially have been masked by the ablated primary tachycardia, was performed. Paroxysmal SVT was classified as AVNRT, AVRT, AT, or Wolff-Parkinson-White Syndrome. Patients with slow pathway ablation due to dual AV node physiology (DAVNP) were also defined as paroxysmal SVT. Patients were prescribed acetylsalicylic acid for 1 month after ablation and discharged without antiarrhythmic medication. All of the patients were systematically examined by a cardiologist at least one and 6 months after ablation as part of routine clinical follow-up.

Definitions

Arterial hypertension was defined as patients with repeated blood pressure measurements ≥140/90 mmHg or a previous diagnosis of hypertension with usage of antihypertensive drugs. Diabetes mellitus was defined as fasting plasma glucose levels >126 mg/dL in multiple measurements or glucose level over 200 mg/dL at any measurement or active use of antidiabetic medications. Smoking was defined as current smoking in the previous six months. Hypercholesterolemia was defined as a baseline cholesterol level of >200 mg/dl or a low-density lipoprotein cholesterol level of >130 mg/dl or previously diagnosed and treated hypercholesterolemia. Coronary artery disease (CAD) was defined as electrocardiographic signs of prior myocardial infarction or echocardiographic findings of left ventricular wall motion abnormalities indicating myocardial infarction or history of previous percutaneous coronary intervention or coronary artery bypass graft operation. In addition, angiographically proven severe coronary artery stenosis >50% were defined as CAD.

Statistical analysis

Patients’ demographics, clinical, and electrophysiologic characteristics are presented as number and percentage reflecting frequencies. Continuous variables are expressed as mean±SD.

Results

Clinical characteristics and electrophysiological features of the study population are presented in Table 1. Mean age of the study population was 45 ± 10 years, minimum and maximum ages of the study population were 18 and 78 years, respectively. There were 81 female (81%) and 19 (19%) male patients. Multinodular goiter, diabetes mellitus, hypertension, and hyperlipidemia was present in 3%, 4%, 10%, and 7% of the patients, respectively. Sixteen percent of the patients were current smoker. Among those 3 patients who had been followed by the diagnosis of multinodular goiter, 2 patients underwent ablation procedure of AVNRT, one patient underwent ablation of DAVNP, and their thyroid function tests were found to be within normal range. CAD was diagnosed in 11 (11%) patients. In addition, 11 (11%) patients had angiographically proven normal coronary arteries. During EPS and ablation procedures, AVNRT was the most common detected and successfully ablated SVT type in 58% of the patients, and successful ablation of DAVNP was performed in 21% of the study population. AT was detected and ablated successfully in 12% of the patients. AVRT was detected and successfully ablated in 7% of the study population, and Wolff-Parkinson-White Syndrome was present and ablated successfully in 2% of the patients.

Table 1 - Clinical and electrophysiological characteristics of the study population
Parameters Number (%)
Age, y 45±17
Male/female 19/81
Diabetes mellitus 4 (4%)
Multinodular goiter 3 (3%)
Hypertension 10 (10%)
Hyperlipidemia 7 (7%)
Smoking 16 (16%)
Coronary artery disease 11 (11%)
Electrophysiological study diagnosis
 AVNRT 58 (58%)
 DAVNP 21 (21%)
 AVRT 7 (7%)
 AT 12 (12%)
 WPW syndrome 2 (2%)
AT, atrial tachycardia; AVNRT, atrioventricular nodal reentrant tachycardia; AVRT, atrioventricular reentrant tachycardia; DAVNP, dual atrioventricular node physiology; WPW, Wolff-Parkinson-White.

The frequency of patients’ symptoms during the PSVT event is given in descending order in Table 2. The mean and median duration of symptoms before EPS and ablation procedure was 60 months (ranging from 1 week to 20 years) and 24 months, respectively. Palpitation was the most frequently observed symptom in 84% of patients, followed by chest pain in 47%, dyspnea in 38%, syncope 26%, lightheadedness in 19%, and sweating in 18% of the patients. Less frequently, paresthesia was observed in 9%, nausea or vomiting in 8%, uncontrollable shaking or tremor in 5%, headache in 4%, feeling of coldness in 2%, involuntary crying in 2%, speaking disability in 2%, burning sensation of whole body in 2%, abdominal pain in 1%, and tinnitus in 1% of the patients. In addition to these symptoms, 15% of the patients reported emotional disturbances or stress just before the onset of tachycardia, 17% of the patients reported relationship with their body motion such as bending over, sitting down, crouching or lying down just before the onset of PSVT. However, 94% of the patients reported unexpected occurrence of PSVT event. Common and uncommon symptoms during PSVT event are illustrated in Figure 1.

Table 2 - Symptoms of patients during the paroxysmal supraventricular tachycardia or index event
Symptoms Number (%)
Palpitation 86 (86%)
Chest pain 47 (47%)
Dyspnea 38 (38%)
Syncope 26 (26%)
Lightheadedness/dizziness 19 (19%)
Sweating 18 (18%)
Paresthesia 9 (9%)
Nausea/vomiting 7 (7%)
Uncontrollable shaking or tremor 5 (5%)
Headache 4 (4%)
Feeling of coldness 2 (2%)
Speaking disability 2 (2%)
Involuntary crying 2 (2%)
Burning sensation in whole body 2 (2%)
Tinnitus 1 (1%)
Abdominal pain 1 (1%)

Fig. 1
Fig. 1:
Schematic illustration of common and uncommon symptoms during supraventricular tachycardia or index event. AVN, atrioventricular node; SG, sympathetic ganglions; SN, sinus node; SVT, supraventricular tachycardia.

The frequency of post tachycardia symptoms of patients within the preceding hours or days is presented in Table 3. The most common symptoms after tachycardia or index event were fatigue and lightheadedness with frequencies of 56% and 55%, respectively. Forty-five percent of the patients reported more than one, unusually frequent urination following the 1–3 hours period immediately after the index event. During the post-attack period, approximately 10% of the patients also reported additional symptoms different from those of during tachycardia attack, such as chest pain, paresthesia, headache, nausea, and somnolence, diarrhea, yawning, and feeling of coldness. Fifteen percent of the patients denied suffering from palpitation during the index event. On the other hand, palpitation was the single symptom in 17% of the patients, chest pain in 3%, syncope in 4%, dyspnea in 1%, lightheadedness in 1% of the patients, who were successfully ablated. It is worthy of note that a female patient who had been followed-up with the diagnosis of epilepsy for 20 years recovered from so-called epileptic attacks. After 6 months follow-up period, all patients did not have any symptoms when compared with the preprocedural ones.

Table 3 - Post tachycardia symptoms within the preceding hours or days
Symptoms Number (%)
Fatigue 56 (56%)
Lightheadedness/dizziness 55(55%)
Polyuria 45 (45%)
Chest pain 7 (7%)
Paresthesia 2 (2%)
Headache 1 (1%)
Nausea 1 (1%)
Somnolence 1 (1%)
Diarrhea 1 (1%)
Yawning 1 (1%)
Feeling of coldness 1 (1%)

Discussion

Palpitations are one of the most common problems of outpatient clinics, accounting for 16% of admission complaints [5]. A considerable amount of those population consisted of patients with SVT [6]. The prevalence and incidence of PSVT in general population was reported as 225 per 1000 person and 35 per 100 000 person-years, respectively, according to documented ECG records [3]. However, the real-world prevalence is supposed to be higher owing to non-documented and undiagnosed PSVT cases due to unusual or overlooked symptoms [2]. In contrast to tremendous achievements in electrophysiological and ablative techniques and equipment, reports evaluating the symptoms of PSVT are very limited in the literature. In addition to palpitation, dyspnea, chest pain, syncope, sweating, lightheadedness, dizziness, and anxiety are the other common symptoms of PSVT [3,7]. Besides, PSVT may be unrecognized at initial medical evaluation, and the clinical characteristics can mimic panic disorder [8]. It might remain undiagnosed even for years as in our previous reports [9–11]. Although documentation of index tachycardia has pivotal role to make a clinical correlation with symptoms and to make a correct diagnosis for guiding therapy, it may not be so in clinical practice.

Diagnostic difficulties of PSVT come from the short duration and paradoxical nature of index event, unusual presentation of SVT and differences in patients’ perception of index event. Unusual presentation of index event or non-cardiovascular symptom may misdirect the clinician against the presence of PSVT as an underlying cause. However, these symptoms in the presence of a high suspicion index and paradoxically occurring course can be used as adjunctive signs not to overlook the presence of PSVT [2]. Unusual presentations of PSVT, such as tinnitus, burping, chilling, absence-like seizure, asthma-like attacks, have also been reported in the literature [9,10,12–14]. Clinical ECG documentation of paroxysmal on-off tachycardia, despite all efforts, might result in a diagnostic mass. In these circumstances, patients clinically suspected to have PSVT are still referred to qualified centers for EPS without preprocedural ECG documentation of the tachycardia. However, detailed symptomatic assessment of PSVT has not been documented in a systematic manner or algorithmic approach yet, even in the recently published guidelines [15,16]. In this study, we have demonstrated that patients with PSVT suffer from palpitation, dyspnea, chest pain, lightheadedness, and syncope in accordance with the literature, albeit the frequency of chest pain is higher than previous reports in our study population. In addition, we have also documented unusual symptoms which are rarely or never mentioned in the literature. Sweating, paresthesia, nausea and vomiting, uncontrollable shaking headache, feeling of coldness, speaking disability, involuntary crying, tinnitus, burping, burning sensation in whole body, abdominal pain have been described in our study population in a considerable frequency ranging from 1% to 18%. Post-event complaints, namely, polyuria, lightheadedness, and fatigue, have been observed almost in the same frequency of 50% in the study population. Moreover, 7% of the patients (n = 7) have described chest pain lasted 1–3 hours following the index event. Additionally, one patient complained of somnolence, one patient yawning, one patient headache, one patient diarrhea, one patient sensation of coldness, and one patient complained from nausea.

The mechanisms of these symptoms can be explained partially by the direct hemodynamic effects of SVT itself, or increased sympathetic activity due to emotional situation, psychosomatic contribution, cross-talk between the heart and central nervous system thorough sympathetic ganglions and vagus nerve or the mechanisms which we are not aware of those yet. Although the mechanism of chest pain is not clear, troponin positivity has been reported in up to 30% patients with PSVT [17]. In undocumented patients, this might result in repetitive coronary angiographies. Although there is still controversy about the mechanism of syncope, it has been supposed that decreased vasomotor tone rather than the increased heart rate is the more important causative factor for syncope in patients with PSVT [18,19]. Some patients describe fatigue lasting several hours to days after an episode of SVT, although the mechanism is not known yet [20]. Diuresis has been reported to occur in 20%–50% of episodes of paroxysmal SVT [21–23], which is also consistent with our results. Increased atrial natriuretic peptide and decreased vasopressin release have been supposed to be the mechanism of polyuria after SVT episodes [24]. Although it has never been assessed in the literature, it can be speculated that diuresis, kaliuresis, natriuresis, and subsequent hypotension can be the underlying cause of post-attack fatigue and dizziness in PSVT patients. Cross-talk is another mechanism to explain the unusual symptoms, such as tinnitus, burping, seizure in patients. Likewise, simultaneous recording of PSVT has been documented during the attacks of status epilepticus[25,26] and absence-like seizure [10]. Indeed, regarding the role of vagus nerve in gastrointestinal symptoms of inferior myocardial infarction, similar pathway might be proposed to explain the mechanism of symptoms, such as nausea, vomiting, abdominal pain, diarrhea as well. Similar to referred pain in cardiac ischemia, cross-talk with cranial nerves at the cervical ganglions level or cross-talk through the transmission of impulse from spinal cord to the thalamus might have resulted in different presentation of symptoms as in the case of tinnitus or absence seizure [10,27,28]. Indeed, vagus nerve drives the afferent fibers of many visceral organs and is an integral part of this heart-brain system, which are connected bi-directionally due to the efferent outflow from the brain affecting the heart and the afferent outflow from the heart affecting the brain [29,30]. It is likely that symptoms such as nausea, abdominal pain, burning sensation or coldness, involuntary crying, speaking disability can be explained by vagus nerve mediated mechanism triggered by PSVT through the cross-talk of cardiac afferent nerves with cranial nerves or cervical ganglions during the propagation of impulses to thalamus.

There are several inferences which can be driven from our observational results: (1) Palpitation is the most frequent symptom of PSVT as expectedly, however, there are many associated unusual symptoms during PSVT, (2) Almost one-fourth of PSVT cases manifest itself with single symptom, such as palpitation, syncope, chest pain, dyspnea, and lightheadedness. (3) Post-attack symptoms of polyuria, lightheadedness, and fatigue occur in almost half of the patients in association with less frequent unusual concomitant symptoms. However, there are some limitations of this study. First, this was an observational, single-center, retrospective study with a relatively small number of patients. Further prospective studies with multicenter collaboration and higher number of patients are needed to validate our results. In addition, further studies evaluating the symptoms of PSVT during and after the attack are warranted to establish a diagnostic algorithm for patients suffering from PSVT.

In conclusion, PSVT might manifest itself as gastrointestinal, neurological, psychosomatic symptoms, and unusual complaints in association with or without main symptoms, including palpitation, chest pain, syncope, and dyspnea. Detailed evaluation of the main symptoms and unusual concomitant symptoms might be helpful to pay attention for the diagnosis of PSVT especially in patients with non-documented but suspicion of tachycardia.

Acknowledgements

The authors would like to thank Yagmur Yetkin for her drawing on the illustration of symptoms.

All authors have substantial contributions to conception and design, or acquisition of data, analysis, and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published.

Conflicts of interest

There are no conflicts of interest.

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Keywords:

ablation; electrophysiological study; paroxysmal supraventricular tachycardia; symptom

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