An Athletic 37-Year-Old Woman With Suspicious Panic Attacks

Thomas J. Hemingway, MD

Disclosures

September 01, 2020

The initial treatment for acute tachycardia is as described in the AHA's ACLS protocol.[1] In many cases of narrow-complex tachycardia, adenosine can be helpful in both the diagnosis and, depending on the underlying arrhythmia, the treatment to stop the cycle of the arrhythmia; however, patients who have the typical narrow-complex atrioventricular reentrant tachycardia associated with WPW syndrome can theoretically be at risk for harm. This is not just because adenosine can prolong conduction and refractory time in the atrioventricular node, promoting conduction down the accessory pathway, but also because of a small risk of precipitating atrial fibrillation with adenosine.

Digoxin is absolutely contraindicated in atrial fibrillation because it may shorten the refractory period and enhance conduction over the bypass tract, resulting in even faster conduction to the ventricles and increasing the risk for ventricular fibrillation. If the diagnosis is made early, the American College of Cardiology (ACC)/AHA guidelines for the management of atrial fibrillation in WPW syndromes list direct-current (DC) cardioversion, ibutilide to break the atrial fibrillation, and procainamide as class I treatment options.[6] Amiodarone has a class IIb indication. Digoxin and nondihydropyridine calcium channel blockers are listed as class III agents because of the potential harm that they can cause.

As mentioned above, some patients with WPW syndrome are at risk for sudden death. In these patients, a cardiac electrophysiology study and radiofrequency catheter ablation may be definitive and curative. ACC/AHA guidelines for radiofrequency ablation (RFA) list symptomatic patients with drug-resistant accessory pathway arrhythmias or atrial fibrillation in preexcitation syndromes as class I indications for RFA.[6,7]

A family history of sudden cardiac death in patients with accessory pathways has a class IIa indication. Because of the association with family history, research is underway to identify the underlying molecular and genetic mechanisms that result in the development of such accessory pathways.[8,9] Reviewing family history is important in patients who present with these syndromes. The patient in this case did not have an immediate family history of sudden cardiac death. Data also support radiofrequency ablation in asymptomatic patients who may be at high risk for atrial arrhythmia as recognized by electrophysiology studies.[10] ACC/AHA guidelines include a class IIa recommendation for asymptomatic patients whose jobs, livelihood, or safety may be adversely affected by arrhythmia.[6,7]

Given this patient's history of severe symptoms and her presentation with atrial fibrillation, the cardiovascular electrophysiology service recommended radiofrequency ablation. She underwent the procedure during her admission and had no complications. At 3-month follow-up, she was free of any need for antiarrhythmic medication. In addition, she noted that she did not have any further "panic attacks" in that timeframe, and her primary care provider was planning to wean her off of the SSRI.

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