Cardiology factors prominently in psychiatry and psychiatric
care. I have been fortunate on many occasions to work with psychiatrists who
were also cardiologists and to have access to outstanding cardiologists as
consultants. That gave me a great appreciation for what was possible in the
detection treatment of cardiac problems. It also help me appreciate the
importance of treating psychiatric disorders in patients with cardiac problems.
The recognition that some medications can cause problems and the need for ECG
screening was another change in psychiatric practice. Prior to that knowledge,
there were some medications that delayed cardiac conduction to the point that
they are no longer used.
One of the commonest scenarios I currently see is at the
interface of anxiety and the effect it has on the heart. About 20 to 30% of the
people I see have severe anxiety and panic attacks. About two thirds of them
have made at least one trip to the emergency department because they thought
they were experiencing a heart attack. They are generally young people with
limited cardiac risk factors. When I asked them about the symptoms that led
them to the ED, the most common answer is “my heart was pounding out of my
chest and I thought I was having a heart attack”. Palpitations are another
common symptom. They are harder to get at and people who have talked to
cardiologists are better at describing them. I demonstrate by making an
irregular thumping noise on my chest with my hand to indicate what it might
feel like. The associated symptoms of panic attacks like swelling,
lightheadedness, dizziness, chest tightness, shortness of breath,
hyperventilation, and dizziness all reinforce the thought of a heart attack.
Once the ED staff determine the patient is having a panic attack the way they
are educated is critical in reducing ongoing symptoms. But that is another
story.
An associated symptom in anxiety is what I like to call “cardiac
awareness”. It happens in anxious people whether they have an anxiety disorder
diagnosis or a stressor making them anxious. Laying in bed at night waiting to
fall asleep many people can sense their heart beating without taking their
pulse. They can sense other pulse points in the body and frequently they can
sense large pulsations. This is a normal physiological process but anxiety can
lead to a focus on it. I also lead to attaching other meetings to it such as
the occasional palpitation is seen as evidence of heart disease leading to
increased anxiety. In that situation it becomes very difficult to sleep leading
to more anxiety and frequently - a faster heart rate the next day.
Cardiac pathology can compound the problem because there are
various conditions like atrial fibrillation that can lead to people paying much
more attention to their heart rate and rhythm. Atrial fibrillation is
interesting in that regard because there are two management strategies. In a
rate control strategy the person is given a medication to generally keep their
heart rate less than 100 bpm but the rhythm could still be irregular and
experienced as frequent palpitations. In a rhythm control strategy the person
is either given a medication or treatment to maintain a regular sinus rhythm
and palpitations would be much less frequent to nonexistent. Current thinking
on treating atrial fibrillation is that the outcomes of both strategies are
equivalent in terms of mortality but that patients with a rhythm control
strategy rate themselves as having a higher quality of life.
That brings me to the New
England Journal of Medicine case listed in the references below. This case continues a recent trend in
incorporating more psychiatric expertise into these cases with psychiatrists as
discussants. The patient was a 62-year-old man with depression and anxiety. The
depression dated back 15 years with onset after he learned that his wife had
cancer. His wife eventually died. Whichever psychiatrist are about seven years
and eventually found that citalopram and clonazepam are effective. He continued
with his primary care physician and eventually discontinued the citalopram. He
was seen by one of the discussants due to recurrent anxiety depression and
lethargy. Vital signs were noted to be abnormal with an irregular pulse of 130
bpm blood pressure 108/75. An ECG was done that showed new onset of atrial
fibrillation.
Echocardiography showed an enlarged left atrium and left
ventricle, low normal LV ejection fraction, mild left ventricular hypertrophy,
and no valvular disease. The subsequent ECG showed a prolonged QTc interval of
466 ms. At a subsequent visit he had an additional significant stressor also
had started to binge drink. At that time he had weekly panic attacks that
correlated with increased alcohol intake. When he was seen in the psychiatric
clinic had weekly panic attacks that consisted of “racing heart,
lightheadedness, restlessness, shaking, and generalized weakness and so the
episodes lasted for several hours. A family history of depression and suicide was
noted. He was noted to be drinking 4 to 6 standard drinks per week with
occasional binges. Aripiprazole was added to the clonazepam and citalopram.
The patient subsequently had a near syncopal episode three weeks
later I was noted to be hypertensive and tachycardic. The ECG showed atrial
fibrillation and sinus pauses of six and seven seconds. A permanent pacemaker
was placed in the metoprolol was discontinued.
He was noted to be improved on the psychiatric medication
changes but the metoprolol is discontinued because of fatigue. Three weeks
later he had increasing anxiety and the feeling that his heart was racing and “thumping”
in his chest and that he was excessively worried. They aripiprazole was increased at that time.
Like most of these cases there is a differential diagnosis
exercise included and the discussant in this case is a psychiatrist. The exercise focuses on the fact that the
central symptoms in this case-anxiety, palpitations, racing heart,
restlessness, and fatigue are not specific for cardiac or psychiatric
diagnosis. In fact all DSM diagnoses included criteria to rule out any medical
causes of the syndrome. In this case all the usual suspects are discussed. From
the medical side hyperthyroidism, return atrial fibrillation, dilated
cardiomyopathy, Torsade de pointes, and rare medical causes are discussed. The duration
of the patient’s symptoms rules out a lot of the acute causes. From psychiatric
standpoint panic disorder, substance intoxication, and substance withdrawal
were the primary considerations. The discussant Dr. Chen uses the term that we
don’t hear enough of lately and that is parsimony specifically “The best
diagnosis would parsimoniously explain the patient’s symptoms and the time
course of his illness”. He concludes that there is a clear correlation with
discontinuing metoprolol and experiencing recurrent atrial fibrillation.
From a cardiology standpoint the decision was made to
improve rhythm control with sotalol and the rationale for choosing that agent
was provided. He experienced a decrease number of episodes of atrial
fibrillation that he was correlating with anxiety.
The discussion highlights the correlation of anxiety with
atrial fibrillation. That anxiety is a product of experiencing the palpitations
and also can be an etiological factor in the episodes of atrial fibrillation.
Depression and anxiety also predict who experiences more severe symptoms of
atrial fibrillation. Patient medications also discussed in terms of the
prolonged QTc interval. The authors comment on the FDA warning about QTc
prolongation with higher doses of citalopram. They point out that although
citalopram prolongs QTc interval more than other antidepressants there is
little evidence that it leads to torsade de pointes or sudden cardiac death. They also point out that the literature shows that when this warning led to
decreasing the dose of citalopram the result was no worsening of cardiac outcomes but less than optimal psychiatric outcomes including more frequent
hospitalizations and increased sedative hypnotic prescriptions.
Overall this was an excellent discussion of the
cardiology-psychiatry interface. Psychiatrists are likely to see increasing
numbers of patients with atrial fibrillation. I currently see number of
patients who are taking multiple cardiac medications. Any patient with this
degree of complexity it is important to discuss the possibilities in order to
determine the likely sequence of events. In patients with cardiac risk factors who
are hypertensive and appear to be describing panic attacks caution is necessary
to make sure that there are no underlying cardiac conditions that need to be
attended to. As illustrated in this case I have seen patients with severe panic attacks (but no atrial fibrillation) due to the abrupt discontinuations of metoprolol. In patients who have recently discontinued antihypertensive therapy and have panic attacks - clarifying whether there has been any exposure to beta blockers is important.
Another relevant factor in this patient's demographic is that the sympathetic tone of the peripheral nervous system in humans seems to increase with age. That may predispose older populations to tachycardia, palpitations, hypertension, and anxiety either directly or indirectly by experiencing the cardiac symptoms.
Another relevant factor in this patient's demographic is that the sympathetic tone of the peripheral nervous system in humans seems to increase with age. That may predispose older populations to tachycardia, palpitations, hypertension, and anxiety either directly or indirectly by experiencing the cardiac symptoms.
Being able to make an assessment and determination of
patient stability, whether or not they need urgent care, what further testing
is needed, and what further referrals are necessary is a skill that every
psychiatrist should have.
George Dawson, MD, DFAPA
Reference:
See also for the critical references in this case.
Graphics Credit:
The human heart line drawing in the above graphic is from Shutterstock per their standard agreement.
