The Case

At the age of 16, an otherwise healthy woman began feeling “woozy” after her high school gym classes. She described it as “not a black-out but a feeling of a white-out” occurring roughly once every month or two. Her symptoms were abrupt in onset and she felt her heart was racing and pounding like it was going to jump out of her chest. The symptoms lasted between 5 and 15 minutes, and then subsided after sitting down. There was no family history of heart disease. Over the ensuing years, similar episodes occurred occasionally, usually related to stress, such as while giving presentations to large audiences.

When the patient was in her 30’s, she went through a period of significant emotional and financial stress, having just broken up with her longtime boyfriend, and suffered some loss of income.  At a time when she was feeling particularly stressed, she experienced a more severe episode that she described as “her heart pounding.”  She went to a local emergency department (ED) thinking she might be having “a heart attack.” She had a normal electrocardiogram (ECG) and was discharged with a diagnosis of “likely stress reaction/possible panic attack.” She felt embarrassed for having gone to the ED and although she continued to periodically have these symptoms, she did not mention them to anyone. Two years later, the symptoms occurred while on a bicycle ride, requiring her to dismount and sit on the side of the road for 45 minutes until the symptoms subsided. After this attack, she scheduled a primary care appointment.

After taking her social history, the physician suggested that she see a psychiatrist for presumed panic attacks. Based on her internet reading, she asked if this could be a heart rhythm problem. The physician reluctantly ordered a 24-hour Holter monitor, which came back “normal,” although she did not have any symptoms while wearing the monitor. 

At the age of 40, the patient had another severe episode during which she felt a twinge of chest pain, and again went to an ED. The ECG was normal and she was referred for a cardiac exercise treadmill test, which was normal for the first 8 minutes. However, at 9 minutes, she began to experience one of her “woozy” spells and the ECG showed a regular heart rate of 230 beats per minute with narrow QRS complexes. She was relieved to be “finally diagnosed” as having paroxysmal supraventricular tachycardia (PSVT) after more than two decades of experiencing these symptoms.

The Commentary

By David T. Martin MD and Diane O’Leary PhD

Background

The adult human heart beats approximately 100,000 times every day and conscious awareness of the heart beating is not normal. However, the symptom of palpitation is common and may be defined as an abnormal awareness of the heart beating. This sensation is described by patients in a variety of ways such as a forceful or irregular heartbeat, a rapid or flip-flopping sensation. The symptom may be very brief such as may occur with premature beats or sustained, with or without a sensation of tachycardia. Palpitations may be felt in the chest, upper abdomen or neck. The symptom of palpitation may be caused or associated with a number of underlying physiologic states or disorders as outlined in the table below.

Table. Causes of Palpitations

Paroxysmal supraventricular tachycardia (PSVT) is very common. Estimated annual population incidence of PSVT, as reported in the peer-reviewed literature, ranges from 9.5 to 97 per 10,000 persons, depending on age and sex, with the highest prevalence in persons over 65 years of age.^1,2 Unlike ventricular tachycardia, PSVT is usually a benign and self-limited arrhythmia, although in rare circumstances it can be associated with an extremely rapid and life-threatening heart rhythm.

A recent study of commercial and Medicare insurance claims covering over 18 million adults from 2008 to 2016 reported that about 67% of identified patients with PSVT were female; period prevalence increases with age in both sexes up to 84 years.³ Women with PSVT are more commonly misdiagnosed as experiencing anxiety, stress, or panic attacks and are referred later than men for catheter ablation.⁴ The stigma of assigning a psychiatric diagnosis for such symptoms early in the course of an evaluation (premature diagnostic closure) may lead to delay in diagnosis of PSVT, as occurred in this case.

Ambulatory ECG monitoring may be prescribed for patients presenting with palpitations. In patients with palpitations who undergo long-term ambulatory ECG monitoring, the most common finding is ectopic beats of either atrial or ventricular origin. Monitoring for only brief periods, as was performed in this case, frequently does not permit correlation of patients’ symptoms with cardiac rhythms because arrhythmia episodes may be too infrequent to occur during monitoring. Therefore, utilizing either long-term continuous ambulatory monitoring or consumer electronic monitoring devices may be more useful.

On the other hand, up to half or more of patients who present with palpitations do not have any identified cardiac etiology, even after thorough evaluation by cardiologists, including either ambulatory or exercise ECG.^5,6 Researchers have tried to link this finding to psychiatric disease. For example, Barsky and colleagues reported in 1994 that approximately 45% of patients referred for Holter (24-hour) monitoring because of palpitations or similar symptoms had a lifetime history of an underlying psychiatric disorder as assessed by a standard survey instrument.⁷ Although the study was methodologically rigorous, it now seems clear that panic disorder and anxiety are commonly diagnosed when patients actually suffer from PSVT. At another academic medical center, Lessmeier et al found that in 54% of patients with PSVT, symptoms had previously been attributed to panic or anxiety, and that error was twice as common in women as in men.⁸

Approach to Improving Safety & Patient Safety Target

This case illustrates the risk of delayed diagnosis and missed diagnosis when patients with PSVT have also experienced panic symptoms. For several reasons, diagnostic caution should be used in cases of this kind. First, the relationship between somatic symptoms and emotional states has undergone reassessment and it has become clear that while emotional disorders may present with somatizing symptoms, it may be equally common to observe heightened emotional arousal precipitated by altered physiologic states. It may be helpful to keep in mind the suggestion from neuroscience that "feelings are mental experiences of body states.”⁹ That is, panic or anxiety often result from, rather than cause, tachycardia.¹⁰ Indeed, ablation has been shown to relieve symptoms in nearly 90% of patients with PSVT, including 29 of 32 patients whose symptoms were attributed to panic, anxiety, or stress prior to the diagnosis of PSVT.⁸

Second, although it is routinely stated that panic disorder is twice as common in women as in men, when panic disorder and PSVT are both in the differential diagnosis, female gender should not favor a diagnosis of panic disorder. Because somatization, anxiety, and panic disorder have long been thought to affect more women than men, clinicians may favor psychiatric explanations in women even when psychiatric and medical explanations are both possible. Previous research suggests that women with PSVT are more likely to be misdiagnosed with mental health conditions before the correct diagnosis is established.^4,8 Longstanding concern about gender inequity in healthcare delivery has now been validated by evidence that women face obstructed access to care that men readily receive in similar circumstances, including access to cardiology,¹¹ stroke care,¹² joint replacement¹³ and cancer screenings.^14,15 Therefore clinicians should proactively consider the role of gender in potentially biasing the diagnostic process in cases of this kind. 

Third, while it is important for clinicians to take steps to root out personal gender bias, they should also recognize that gender bias is also present in diagnostic standards and norms. Diagnostic criteria for panic disorder have not been adjusted in DSM-5¹⁶ to reflect new evidence related to misdiagnosis of PSVT as panic disorder. Current criteria do not include warnings about the greater likelihood of diagnostic error in women presenting with symptoms of PSVT. In cases like this one, avoiding gender-based error depends on clinicians’ individual efforts to factor in the pre-test probability of PSVT, which may be higher among women than among men at younger ages.¹ Ultimately, diagnostic criteria for panic disorder and PSVT should be revised in tandem, including recommendations for working up related symptoms and distinguishing the two conditions. By addressing clinical practices for these conditions together, instead of separately, professional societies can focus attention on helping providers to avoid gender-related and other diagnostic errors.

Fourth, it is important to distinguish PSVT from panic disorder, even knowing that PSVT does not in most cases pose a particularly serious threat. There are psychological consequences to mistaken psychiatric diagnosis in patients who suffer from unrecognized cardiovascular disease; these consequences are exaggerated when untreated disease persists over many years.¹⁷ In this case, premature closure on the diagnosis of “panic attack” led to a mutli-year delay in effective treatment of the correct diagnosis.

Furthermore, clinicians interact differently with patients they believe to be somatizing than they do with patients they believe to suffer from undiagnosed disease, even when effort is made to validate patients’ somatized experience.¹⁸ Therefore, independent of the prognosis or the urgency (or not) of treatment, it is important for clinicians to accurately diagnose patients like the one in this case. By carefully distinguishing psychiatric diagnosis from diagnostic uncertainty, the clinician can correct the clinical record and strengthen patient-provider interactions.

Thus, it is essential that clinicians in the primary care or emergency setting who are evaluating patients with palpitations and related symptoms, such as those presented in this case, avoid premature diagnostic conclusions. Instead, they should recommend monitoring of patients with such symptoms using a technique permitting identification of the cardiac rhythm coincident with episodic symptoms. As a profession, we need to understand that the causal flow between experiential states (such as anxiety or panic) and physiologic states (such as paroxysmal tachycardia) can go in both directions and do a better job of promoting gender health equity.

Take Home Points

• Both paroxysmal SVT and panic attacks are common conditions.
• Although PSVT is for the most part a benign arrhythmia, especially at younger ages, it can be distressing to patients.
• There is significant overlap in the clinical features of both conditions.
• Clinicians responsible for assessing patients with recurrent palpitations should consider ambulatory monitoring with a technique (such as long-term, continuous ambulatory electrocardiographic monitoring) that allows for correlation of symptoms with cardiac rhythm, and should potentially avoid ruling out cardiac disease when symptoms are not reported during the period of ECG monitoring.
• Clinicians should remain aware that the presence of panic or anxiety does not favor the diagnosis of panic attacks, as PSVT can cause similar symptoms.
• Clinicians should recognize that the higher reported prevalence of panic disorder among women may contribute to gender bias and delayed or missed diagnosis of PSVT in women.

David T. Martin MD
Vice Chair, Department of Medicine
Clinical Cardiac Electrophysiologist
Brigham and Women’s Hospital
Harvard Medical School
Boston MA

Diane O’Leary PhD
Independent Researcher
Adjunct Full Professor in Philosophy
University of Maryland Global Campus

Acknowledgements:  

The long-standing process for submitting PSNet WebM&M case submissions is anonymous. Users may contribute by submitting a case at the following link: https://psnet.ahrq.gov/webmm/submit-case. 

Periodically, the Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network, a collaborative project convened by the Brigham and Women’s Hospital Center for Patient Safety Research and Practice and the State of Massachusetts Betsy Lehman Center for Patient Safety, contributes cases and commentaries from their monthly discussions of diagnosis error cases to PSNet. PRIDE is funded by a grant from the Gordon and Betty Moore Foundation. This case was produced in cooperation with the PRIDE Learning Network. We acknowledge the assistance of the PRIDE project director Maria Mirica, PhD, in preparing this Case and Commentary. Editorial support and review for this case was provided by Gordon Schiff, MD.

References  

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