Clinical Challenge: Young Woman With Arm Numbness and Shortness of Breath

Long-term management distinguishes the SVT type, frequency and intensity, risk of therapy, and overall impact on the life of the patient.⁹ Options for long-term management include cardiac ablation and pharmacologic treatments.¹ The most common method of cardiac ablation is radiofrequency (RF) in which an electrode is threaded through a vein or artery into the heart where it coagulates the abnormal tissue. This procedure forms a scar to prevent the targeted area of the heart from preexcitation, permanently in most situations.¹⁰ Pharmacologic treatments for long-term management include beta blockers, diltiazem or verapamil, flecainide or propafenone, amiodarone/dofetilide or sotalol, and digoxin.¹³ Some practitioners have adopted a “pill-in-the-pocket” method of long-term management. “Pill-in-the-pocket” methodology has been adopted for patients with infrequent episodes or for those in need of intermittent treatment.¹¹ This patient demographic is advised to keep prescribed medication in her pocket at all times reserved for an episodic occurrence.

Click to enlarge

Discussion

Patients diagnosed with SVT enjoy excellent prognoses. Reducing the risk of occurring episodes is the primary goal and encompasses lifestyle changes, pharmacologic intervention, or surgery. The goal of treating this demographic is to improve quality of life.⁷ Studies have shown that pharmacologic intervention and cardiac ablation improve quality of life and decrease symptoms, but ablation is superior in eliminating symptoms (74%) vs medication (33%).¹² Table 1 illustrates post-ablation SVT episodes decreasing drastically, increasing physical function, less bothersome symptoms, and decreased impact on routine activities of daily living. Table 2 illustrates abatement of the most common symptoms post-ablation. Recent studies have shown that ablation is not only more effective than pharmacologic interventions in the treatment of certain SVT rhythms, but it is also less expensive.¹³

Untreated or unmanaged, SVT can lead to other possibly fatal heart abnormalities. Patients are advised to practice a cardiac-friendly diet and lifestyle (low sodium, little to no caffeine or alcohol, and minimal stress).

Click to enlarge

Conclusion

Ms. J recovered well from the cardiac ablation. She was placed on limited activity until her follow-up appointment scheduled 1 month post-procedure. She experienced chest pain periodically post-procedure that diminished over time. The cardiologist attributed the chest pain to the extent of ablation on the affected areas of her heart. Months later, Ms J returned to normal daily activity, symptom free.

Providers should be aware that SVT is an often-misdiagnosed condition commonly mistaken as anxiety attacks, heartburn, or even ischemia. Provider education is vital and can aid in the prevention of cardiomyopathies, or even death, depending on the severity and type of SVT. The ultimate treatment goal for SVT patients is to increase and improve quality of life. This further confirms the importance of provider education, appropriate diagnoses, proper follow-up, patient awareness of triggers, and avoidance of modifiable risk factors.

Dinel Ealy, MHS-CLS, PA-S, is a student at Augusta University in Georgia, and Alicia Elam, PharmD, is associate admissions director, Physician Assistant Department, Augusta University.

References

1. Colucci RA, Silver MJ, Shubrook J. Common types of supraventricular tachycardia: diagnosis and management. Am Fam Physician. 2010;82:942-952.
2. Orejarena LA, Vidaillet H, DeStefano F, et al. Paroxysmal supraventricular tachycardia in the general population. J Am Coll Card. 1998;31:150-157.
3. Porter MJ, Morton JB, Denman R, et al. Influence of age and gender on the mechanism of supraventricular tachycardia. Heart Rhythm. 2004;1:393-396.
4. Ko JK, Deal BJ, Strasburger JF, Benson DW. Supraventricular tachycardia mechanisms and their age distribution in pediatric patients. Am J Card. 1992;69(12):1028-1032.
5. Rodriguez LM, de Chillou C, Schläpfer J, et al. Age at onset and gender of patients with different types of supraventricular tachycardia. Am J Card. 1992;70(13):1213-1215.
6. Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Unrecognized paroxysmal supraventricular tachycardia: potential for misdiagnosis as panic disorder. Arch Intern Med. 1997;157(5):537-543.
7. Blomström-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary.  Circulation. 2003;108(15):1871-1909.
8. Wasmer K, Eckardt L. Management of supraventricular arrhythmias in adults with congenital heart disease. Heart. 2016;102:1614-1619.
9. Delacrétaz E. Clinical practice. Supraventricular tachycardia. N Engl J Med. 2006;354(10):1039-1051.
10. Miller JM, Zipes DP. Cardiology patient page. Catheter ablation of arrhythmias. Circulation. 2002;106:e203-e205.
11. Alboni P, Tomasi C, Menozzi C, et al. Efficacy and safety of out-of-hospital self-administered single-dose oral drug treatment in the management of infrequent, well-tolerated paroxysmal supraventricular tachycardia. J Am Coll Card. 2001;37(2):548-553.
12. Bathina M, Mickelsen S, Brooks C, et al. Radiofrequency catheter ablation versus medical therapy for initial treatment of supraventricular tachycardia and its impact on quality of life and healthcare costs. Am J Coll Card. 1998;82(5):589-593.
13. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016;133(14):e506-e574.
14. Wood KA, Stewart AL, Drew BJ, Scheinman MM, Froëlicher ES. Patient perception of symptoms and quality of life following ablation in patients with supraventricular tachycardia. Heart Lung. 2010;39:12-20.

This article originally appeared on Clinical Advisor