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LETTERS TO THE EDITOR |
Department of Cardiology; Wright State University; Boonshoft School of Medicine; Dayton, OH (Derrickson, Baber, Agarwal)
Cardiac arrhythmias have previously been associated with both physical and psychological stress (1–4). Most previous publications on this topic have consisted of correlating patient reports of acute emotional experiences with retrospective interrogation of implantable cardioverter defibrillators (ICDs). For example, ventricular arrhythmias in patients with ICDs significantly increased during the 30 days after the World Trade Center attack on September 11, 2001 (2). We present a witnessed case of ventricular tachycardia during a patient interview in the setting of escalating anxiety.
A 72-year-old man presented to the emergency department with concern because he was shocked by his ICD 6 days earlier while working in a butcher shop. He denied prodromal symptoms of chest pain, palpitations, or shortness of breath. Medication nonadherence was suspected as his wife was blind and he depended on weekly visits from his daughter to organize his medications. His past medical history was significant for severe dilated ischemic cardiomyopathy (ejection fraction 27%) with an ICD placed 4 years previously after an episode of ventricular fibrillation. Concomitant illness included atrial fibrillation, hypertension, diabetes mellitus, and paranoid schizophrenia. Medications included metoprolol succinate, digoxin, sotalol, lisinopril, warfarin, metformin, olanzapine, and lorazepam.
During the review of systems, the patient admitted to suicidal ideations during the previous week. When asked specifically if he had any current suicidal premonitions, the patient became visibly anxious in his response. His apparent apprehension escalated, correlating to the chimes of his telemetry alarm, indicating that his cardiac rhythm had changed from sinus to ventricular tachycardia. This wide complex, monomorphic ventricular tachycardia resolved after 13 beats to a sinus rhythm without a subsequent ICD cardioversion. Besides feelings of trepidation, the patient denied any other symptoms during the event.
Vital signs in the emergency department were temperature 97.5°F, pulse 87 beats per minute, respiratory rate 20 breaths per minute, blood pressure 122/79 mm Hg, and oxygen saturation 92% on room air. Physical examination was significant for obesity, distant heart sounds, and a 2/6 systolic murmur at the apex. Labs including complete blood count, basic metabolic panel, magnesium, thyroid stimulating hormone, free thyroxine, and cardiac enzymes were unremarkable. An electrocardiogram showed a normal sinus rhythm with a rate of 84 beats/minute and a left bundle branch block (QRS duration 170 ms) with no significant change from 2 months earlier. Interrogation of his ICD revealed an episode of ventricular tachycardia before his reported shock 6 days ago. This patient did not experience any further arrhythmias once he was restarted on his home cardiac and psychiatric medication regimen.
This patient is unique in that he had a witnessed event of ventricular tachycardia that was immediately preceded by escalating anxiety during a psychiatric history taking. While corroborating literature suggests a psychosomatic relationship between stress and cardiac arrhythmias (1–4), this appears to be a precedental case report of ventricular tachycardia provoked by unsettling questioning during a patient interview. The pathophysiology of ventricular tachycardia in this case may have been related to his escalating anxiety, which increased sympathetic tone leading to an imbalance in the autonomic nervous system regulation (1, 5). While this patient's arrhythmia was short-lived and without lethal sequelae, this case suggests that potentially anxiety-triggering questions should be carefully approached in this patient population, especially if medication nonadherence is suspected.
DOI:10.1097/PSY.0b013e318159e7bd
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