DISCUSSION
The main findings of this study demonstrate that catheter ablation can
lead to a decrease in mean total psychiatric medications in PSVT
patients that were being treated with psychiatric medications. Previous
studies demonstrated that ablation improve subjective symptoms through
scoring systems [7,8,10]. This is the first study that provides
objective evidence that mean number of psychiatric medications
significantly decrease in these patients.
Paroxysmal Supraventricular Tachycardia (PSVT) is defined as a clinical
syndrome noted by the presence of regular and rapid tachycardia [1].
Palpitations, dyspnea, hyperventilation, syncope, sweating, chest pain,
and anxiety are the most reported symptoms [2]. Our study
demonstrated similar presentations with the most common complaint being
palpitations. In a previous study, 67% of patients with PSVT had
symptoms that were consistent with the diagnosis of panic disorder,
based on the Diagnostic and Statistical Manual of Mental Disorders
(DSM)-IV [6]. Per the updated DSM-V, the criteria remain similar and
therefore PSVT could continue to remain mis-diagnosed as a panic or
anxiety disorder [11].
It has been reported that anxiety may be exacerbated by PSVT episodes.
The sudden onset of PSVT can trigger anxiety disorders in patients
[3]. One study reported that anxiety disorder has been present in
approximately 25% of patients with PSVT; interestingly, the same study
reported that PSVT was unrecognized in over 50% of the time [6]. As
anxiety levels increase, patients are at an increased risk for further
PSVT [5,9]. Therefore, patients can often get caught between anxiety
and panic attacks between episodes of PSVT. This confounds the clinical
picture, leading to misdiagnosis, incorrect management and potentially
escalating anti-anxiety medications.
Catheter ablation is a Class 1 recommendation for the treatment of PSVT
based on the 2015 American College of Cardiology/ American Heart
Association/ Heart Rhythm Society guidelines [1]. Ablation has a
high success rate, greater than 93% dependent on the mechanism
[12,13] with a minimal complication rate [12]. It is highly
effective for eliminating further episodes of PSVT [14,15] and has
been proven to be cost-effective when compared to chronic antiarrhythmic
drug therapy [8, 16-19]. However, there has been less evidence on
the effects of ablation on anxiety in patients with PSVT. Current
studies utilized subjective scoring systems to demonstrate improvement
in these psychiatric disorders. Yildrim et al utilized the WHOQOL-BRIEF
domain scores [8, 20] and demonstrated a statistically significant
improvement post-ablation. Papiashvilli et al utilized the State and
Trait Anxiety Inventory (STATI) and found that PSVT patients had
improved situational and general anxiety levels [7, 21]. The same
group also utilized the Short Form health questionnaire (SF-36) and
found significant improvement in physical, social, and emotional health
scores after ablation [10, 22]. Our study further supports this data
by providing objective evidence of the effect of PSVT ablation on
anxiety disorders.
We examined the mean number of medications and found a significant
decrease in the average number of psychiatric medications. We also
examined different types of medications including SSRIs, SNRIs,
anxiolytics such as bupropion, buspirone, and trazadone,
benzodiazepines, and antipsychotics. These medications were chosen due
to the current medical management of anxiety and panic disorders
[23,24]. SSRIs and SNRIs are often the first line treatment for
anxiety. Typically, one agent is chosen and titrated up to the maximum
dose. If the medication does not provide a desired outcome, the patient
is switched to another agent and the process is repeated. Cases that are
refractory will be supplemented with other anxiolytics or
benzodiazepines as needed [25]. If the anxiety is uncontrolled with
the previous process, antipsychotics may be utilized [26].
Therefore, we wanted to look at the total number of psychiatric
medications, as well as each individual subtype, as a measure of anxiety
disorder severity. For patients with uncontrolled anxiety, we expect the
average number of psychiatric medications to increase based on current
guidelines. We found that patients with SVT ablation was associated with
a decrease in the average number of psychiatric medications. Due to
having similar symptoms, SVT may have been misdiagnosed as anxiety and
panic disorders, leading to excessive psychiatric medications. Ablation
then abated symptoms and may have led to decreased average number of
psychiatric medications.
The main limitation of our study was the sample size. Other modes of
managing anxiety, such as cognitive therapy, exist [27] but were not
recorded. Larger prospective studies may be needed to further examine
the relationship with psychiatric medications, cognitive therapy, and
SVT ablation.