The National Women's Health Information Center's Featured Health Articles
 Article for February, 2006
Don't Panic! There are Simple Treatments for Many Heart Arrhythmias
By John F. Beshai, MD
Assistant Professor of Medicine
Cardiac Electrophysiology
Emory University Hospital
Atlanta, GA
"To someone with a hammer," goes the old saw, "everything is a nail." It would be funny if it weren't so tragic in the case of medical diagnoses.
In a busy primary care office, physicians can often gravitate toward a simply and easily derived diagnosis of panic disorder to explain abnormal heart rhythms. But patients with heart palpitations – particularly female patients – should be wary of receiving a psychiatric diagnosis to explain irregular or fluttering heart beats. A different set of diagnostic tools and some further digging can uncover an organic and highly treatable basis for an irregular heartbeat. Although there is minimal data on patients who are misdiagnosed with panic disorder, I do see a fair amount of patients desperately seeking second opinions regarding the cause of their palpitations.
That's what happened to Shirley Sellers, a diver and dive shop owner, whose treatment for panic disorder left her grounded. Medications were unsuccessful in quelling the palpitations, and the ongoing symptoms themselves were generating a measure of, if not panic, then significant concern.
I identified her rapid, irregular heartbeat as atrial fibrillation which is an electrical abnormality involving the upper chambers of the heart. This abnormal rhythm results in a "quivering" of the chambers, not the normal organized contraction of the heart. These rapid, irregular rates can cause palpitations, shortness of breath, and even dizziness – all of which could be mistaken for panic disorder. Using a procedure known as radiofrequency ablation, we were able to cauterize the exact source of her arrhythmia without affecting the underlying function of the heart. Ms. Sellers was discharged from the hospital the day after the ablation, discontinued all medications, and today, she is back teaching and diving with no medical restrictions.
When ‘panic disorders' persist
Patients frequently bring themselves to a cardiologist when the conventional treatment for panic disorder, Xanax or Ativan – does not quell a fluttering heartbeat. Most often patients will be referred to a Cardiac Electrophysiologist, who is a cardiologist specializing in arrhythmias. Typically, a diagnostic protocol might include the following:
Electrocardiogram (EKG): An electrocardiogram, measures the electrical impulses of the heart for a set period. It is typically the procedure performed at rest or during so-called "stress tests" in which a patient runs on a treadmill or performs a similar exercise.
24-hour monitor: These monitors provide a complete picture of heart activity for a full day. They are passive and require no intervention from the patient.
Event recorder: An event recorder captures cardiac activity in discrete increments on a loop that is overwritten every 20 to 40 seconds. It is activated by the patient when a palpitation or symptom occurs, and will record cardiac impulses for, typically, 20 seconds before and 20 seconds after the event.
As a diagnostic tool, an event recorder has a significant advantage over an EKG or even a 24-hour monitor. Both an EKG and 24-hour monitor might miss an arrhythmia that occurs outside the testing period. An event recorder, though, is designed to provide a picture of cardiac activity from the exact moment symptoms appear. Information from the event recorder can be transmitted over a conventional phone line to a physician's office.
Treatments for arrhythmias
Treatment for arrhythmia includes a variety of pharmacological and surgical interventions. Expect your doctor to discuss the following:
Rate-lowering drugs: Beta blockers and calcium channel blockers are prescribed to control the rates of fast heart beats. In addition, they lower blood pressure in situations where patients become quite anxious about their symptoms.
Antiarrhythmic drugs: These medications actually stabilize and maintain a normal heart rhythm rather than just control the rate of the abnormal heart rhythm. Some of these medications may be initiated on an outpatient basis but others may require hospitalization during the initial, high-dose phase of the drug.
Ablation: Radio-frequency ablation is a procedure involving the placement of small tubes in a large vein in the groin under local anesthesia. Catheters are threaded through these tubes into the heart where they record electrical signals. Once we identify the abnormal electrical focus, we deliver radiofrequency energy from the tip of the catheter to create a tiny area of scar tissue and thereby eradicate the arrhythmia. Most patients undergo the procedure on an outpatient basis and are able to return to work without restrictions within 2-3 days.
Worrying about heart palpitations
Heart palpitations can be terrifying. It's not uncommon for a patient to develop a legitimate panic disorder in response to an unresolved heart arrhythmia. Anti-anxiety drugs can sometimes ease but will not completely eliminate heart palpitations that have an underlying physical cause.
In one recent case, a patient diagnosed with panic disorder was found to have an underlying heart arrhythmia. We were able to successfully identify and eliminate the source of the abnormal heart rhythm, but the panic attacks continued. In this case, cardiologists and mental health professionals are working collaboratively to bring the patient back to full mental and physical good health.
Therefore, it is not unreasonable to question a diagnosis of panic disorder in the setting of palpitations and to pursue a thorough cardiac evaluation as the culprit. If an arrhythmia is diagnosed, there is an excellent chance for complete cure and return to enjoyment of life.
This health article is brought to you by our Featured Health Article of the month:
By John F. Beshai, MD
Assistant Professor of Medicine
Cardiac Electrophysiology
Emory University Hospital
Atlanta, GA
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Current as of February 2006
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