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\begin{document}

\title{Supraventricular Tachycardia Ablation and Effects on Anxiety Medications}



\author[1]{Justin Haloot}%
\author[1]{Mohamed  Mahmoud}%
\author[1]{Vanessa Rodriguez Fuenmayor}%
\author[1]{Mubeen Cheema}%
\author[2]{Auroa  Badin}%
\affil[1]{The University of Texas Health Science Center at San Antonio}%
\affil[2]{River Side Methodist Hospital}%


\vspace{-1em}



  
  \date{May 15, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Background: Patients with true paroxysmal supraventricular tachycardia
(SVT) are frequently misdiagnosed with panic or anxiety disorders due to
similar symptoms of palpitations, light-headedness, dyspnea, or chest
discomfort. Unrecognized SVT can lead to unnecessary management with
anxiety medications. Treatment of SVT with catheter ablation may lead to
reduction in anxiety medications. Methods: A total of 175 patients
underwent successful SVT ablation between January 1, 2010 and December
31, 2020. We examined symptoms at presentation, psychiatric medications
prior to SVT ablation, comorbidities, and psychiatric medications at 3
months post-ablation. Results: 15\% of patients who underwent successful
SVT ablation were being treated with psychiatric medications and were
included in the final study population. The most common symptoms were
palpitations (80.77\%), followed by dizziness (42.31\%), and shortness
of breath (34.62\%). The average number of medications prior to ablation
was 1.42 and decreased down to 1.08 at 3 months post-ablation (p =
0.04). The average number of SSRIs, SNRIs, and other anxiolytics were
also decreased but were not statistically significant. Conclusion: In
patients with anxiety and paroxysmal supraventricular tachycardia,
catheter ablation is associated with reduced average number of
psychiatric medications.%
\end{abstract}%



\sloppy


\textbf{Supraventricular Tachycardia Ablation and Effects on Anxiety
Medications}

Justin Haloot, DO\textsuperscript{1}, Mohamed Mahmoud,
MD\textsuperscript{1}, Vanessa Rodriguez Fuenmayor,
MD\textsuperscript{1},

Mubeen Cheema, MD\textsuperscript{1}, Auroa Badin, MD\textsuperscript{1}

\textsuperscript{1} -- University of Texas Health San Antonio,
Department of Internal Medicine, Division of Cardiology

\textbf{Brief Title:} Supraventricular Tachycardia Ablation and
Psychiatric Medications

\textbf{Corresponding Author:}

Justin Haloot, DO

University of Texas Health San Antonio

7400 Floyd Curl Dr.

San Antonio, TX 78229

haloot@uthscsa.edu

ORCID: 0000 -- 0002 -- 6198 -- 7537

\textbf{Co-Author Details:}

Mohammed Mahmoud mahmoud@uthscsa.edu

Vanessa Rodriguez Fuenmayor rodriguezfue@uthscsa.edu

Mubeen Cheema cheema@uthscsa.edu

Auroa Badin badin@uthscsa.edu

\textbf{Data Availability Statement:} The data underlying this article
will be shared on reasonable request to the corresponding author.

\textbf{Funding Statement:} All authors have no financial disclosures.

\textbf{Conflict of Interest Disclosure:} All authors have no conflict
of interest to report.

\textbf{Ethics Approval Statement:} This study was reviewed and approved
by a Western Institutional Review Board (IRB) at the University of Texas
Health San Antonio.

\textbf{Patient Consent Statement:} This study was a retrospective study
without identifying information and patient consent was waived as
approved by the IRB.

\textbf{Permission:} All material is original research and content. We
give permission to reproduce material.

\textbf{Clinical Trial Registration:} None.



\textbf{ABSTRACT}

\textbf{Background} : Patients with true paroxysmal supraventricular
tachycardia (SVT) are frequently misdiagnosed with panic or anxiety
disorders due to similar symptoms of palpitations, light-headedness,
dyspnea, or chest discomfort. Unrecognized SVT can lead to unnecessary
management with anxiety medications. Treatment of SVT with catheter
ablation may lead to reduction in anxiety medications.

\textbf{Methods} : A total of 175 patients underwent successful SVT
ablation between January 1, 2010 and December 31, 2020. We examined
symptoms at presentation, psychiatric medications prior to SVT ablation,
comorbidities, and psychiatric medications at 3 months post-ablation.

\textbf{Results} : 15\% of patients who underwent successful SVT
ablation were being treated with psychiatric medications and were
included in the final study population. The most common symptoms were
palpitations (80.77\%), followed by dizziness (42.31\%), and shortness
of breath (34.62\%). The average number of medications prior to ablation
was 1.42 and decreased down to 1.08 at 3 months post-ablation (p =
0.04). The average number of SSRIs, SNRIs, and other anxiolytics were
also decreased but were not statistically significant.

\textbf{Conclusion} : In patients with anxiety and paroxysmal
supraventricular tachycardia, catheter ablation is associated with
reduced average number of psychiatric medications.

\textbf{KEY WORDS:} SVT, SVT ablation, anxiety, PSVT, PSVT Ablation



\textbf{INTRODUCTION}

Paroxysmal supraventricular tachycardia (PSVT) describes tachycardias
with abrupt onset and termination of regular tachycardias originating
above the bundle of His {[}1{]}. This can include atrial tachycardia, AV
nodal reentrant tachycardia (AVNRT), and AV reentrant tachycardia (AVRT)
{[}1{]}. The prevalence of PSVT has been reported to be approximately
2.29 per 1000 persons and an incidence of 36 per 100,000 persons per
year {[}2{]}. Symptoms of PSVT vary and include palpitations, shortness
of breath, fatigue, chest pain, near syncope, diaphoresis, and anxiety
{[}2{]}.

PSVT has been associated with anxiety and panic disorders. This
association may be due to the sudden onset of tachycardia causing
increased anxiety and stress levels {[}3, 4, 5{]}. However, the symptoms
of PSVT appear to mimic anxiety and may offer another etiology for this
relationship. One study found that 67\% of patients with PSVT could be
diagnosed with panic disorder based on the previous DSM-IV criteria
{[}6{]}. In the same study, it was found that physicians attributed the
symptoms of PSVT to panic, anxiety, or stress in 54\% of patients
{[}6{]}. Multiple studies have found that catheter ablation for PSVT
decreased stress and anxiety levels {[}7, 8, 9,10{]}. However, these
studies utilized symptomatic scoring systems such as the WHOQOL-BRIEF
domain scores and the SF-36 Questionnaire. To date, there has not been a
study examining the effects of PSVT ablation on anxiety related
medication usage.

The purpose of this study is to examine the effect of catheter ablation
on psychiatric medication utilization in patients with paroxysmal
supraventricular tachycardia. We hypothesize that there will be a
decrease in the number of psychiatric medications utilization
post-ablation.

\textbf{METHODS}

Data Source

This is a retrospective analysis of all patients who underwent catheter
ablation procedures for supraventricular tachycardia between January 1,
2010 and December 31, 2020. A research protocol was designed and
approved by the Institutional Review Board (IRB) at the University of
Texas Health San Antonio. Medical records were manually reviewed and
data collected by the research team.

Patient Selection

Patients who underwent a catheter ablation for PSVT from January 1, 2010
to December 31, 2020 were examined. Psychiatric medications that were
prescribed to the patient prior to ablation were recorded. Symptoms of
PSVT were also noted. Patients that were not on any psychiatric
medications and patients with unsuccessful ablation were excluded. Of
the included patients, the number of psychiatric medications at 3 months
post-ablation were noted. Baseline characteristics including age,
ethnicity, gender, and cardiovascular medications were recorded.

Outcome Measures

The primary outcome was the number of psychiatric medications for PSVT
patients pre- and 3 months post-ablation. Patients that were prescribed
psychiatric medications were followed to examine the difference in
number of medications at 3 months post-ablation. Medications evaluated
were serotonin selective reuptake inhibitors (SSRIs),
serotonin-norepinephrine reuptake inhibitors (SNRIs), benzodiazepines
(BZDs), anxiolytics, antipsychotics, tricyclic antidepressants,
buspirone, trazadone, and bupropion.

Statistical Methods

Mean number of psychiatric medications, mean number of SSRIs, mean
number of SNRIs, mean number of BZDs, mean number of other anxiolytics,
and mean number of antipsychotics were analyzed for differences based on
the paired samples t-test. P-values less than 0.05 were regarded as
statistically significant.

\textbf{RESULTS}

Between January 1, 2010 and December 31, 2020, 175 patients underwent
SVT ablation. 15\% of these patients were being treated with psychiatric
medications and were included in the final study population. Patient
characteristics can be found in Table 1. The average age was 50.08 +
17.92 years. 57.7\% were female. 26.9\% had been diagnosed with
hypertension. 65.4\% of PSVT patients taking psychiatric medications had
a formal diagnosis of generalized anxiety disorder. In terms of medical
management, 46.2\% of these patients were on beta blockers, 3.9\% on
calcium channel blockers, 15.4\% on antiarrhythmic medications, and
3.9\% on direct oral anticoagulants (DOACs). With regards to
presentation of PSVT, the most common symptoms reported were
palpitations (80.77\%), followed by dizziness (42.31\%), and shortness
of breath (34.62\%) (Figure 1).

Psychiatric Medications

The average number of psychiatric medications prior to ablation was 1.42
and was reduced at 3 months post-ablation to 1.08 (p-value 0.04). When
breaking down by categories, the average number of SSRIs prior to
ablation was 0.54 and at 3 months post-ablation it was 0.42 (p-value
0.18). The average number of SNRIs decreased from 0.19 to 0.15 (p-value
0.33). The average number of anxiolytics also decreased from 0.31 to
0.19 (p-value 0.18). Finally, the number of antipsychotics remained
stable with an average of 0.12 prior to ablation and 0.15 at 3-months
post-ablation (p-value 0.57) (Table 2).

\textbf{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.

\textbf{CONCLUSION}

In patients with anxiety disorder and paroxysmal supraventricular
tachycardia, SVT ablation is associated with lower average number of
psychiatric medications.



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\textbf{Table 1. Patient Demographics of PSVT Patients Taking
Psychiatric Medications.}

\textbf{Gender}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Male (n, \%) & 11 (42.3\%)\tabularnewline
Female (n, \%) & 15 (57.7\%)\tabularnewline
\textbf{Race} & \textbf{Race}\tabularnewline
Caucasian (n, \%) & 15 (57.7\%)\tabularnewline
Hispanic (n, \%) & 8 (30.8\%)\tabularnewline
African American (n, \%) & 0 (0\%)\tabularnewline
Asian American/ Pacific Islander (n, \%) & 3 (11.5\%)\tabularnewline
Other & 0 (0\%)\tabularnewline
\textbf{Medical History} & \textbf{Medical History}\tabularnewline
Hypertension (n, \%) & 7 (26.9\%)\tabularnewline
Asthma (n, \%) & 8 (11.5\%)\tabularnewline
Chronic Obstructive Pulmonary Disease (n, \%) & 1 (3.9\%)\tabularnewline
Anxiety (n, \%) & 17 (65.4\%)\tabularnewline
\textbf{Other Medications Prior to Ablation} & \textbf{Other Medications
Prior to Ablation}\tabularnewline
Beta Blockers (n, \%) & 12 (46.2\%)\tabularnewline
Calcium Channel Blockers (n, \%) & 1 (3.9\%)\tabularnewline
Anti-Arrhythmic Drugs (n, \%) & 4 (15.4\%)\tabularnewline
Direct Oral Anticoagulants (n, \%) & 1 (3.9\%)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2. Psychiatric Medications of PSVT Patients.}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& \textbf{Pre-ablation} & \textbf{3 months post-ablation} &
\textbf{P-value}\tabularnewline
\midrule
\endhead
\textbf{Mean Number of Psychiatric Medications} & 1.42 & 1.08 &
0.04\tabularnewline
\textbf{Mean Number of SSRIs} & 0.54 & 0.42 & 0.18\tabularnewline
\textbf{Mean Number of SNRIs} & 0.19 & 0.15 & 0.33\tabularnewline
\textbf{Mean Number of Other Anxiolytics} & 0.31 & 0.19 &
0.18\tabularnewline
\textbf{Mean Number of Antipsychotics} & 0.12 & 0.15 &
0.57\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1. Most Common Symptoms of Patients with PSVT and
Prescribed Psychiatric Medications}

\selectlanguage{english}
\FloatBarrier
\end{document}

