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Clinical Scenario: Intermittent SVT in a Patient with PACs

Clinical Scenario: Intermittent SVT in a Patient with PACs

Case Presentation

Patient: 45-year-old male

Chief Complaint: Fatigue and palpitations

History of Present Illness: The patient reports feeling increasingly fatigued over the past month. He also experiences episodes of palpitations, which he describes as his heart racing suddenly for a few minutes before slowing down. These episodes occur sporadically, without clear triggers, and are accompanied by mild dizziness but no chest pain, shortness of breath, or syncope.

Past Medical History:

  • Premature Atrial Contractions (PACs), diagnosed 2 years ago

  • No history of structural heart disease

Medications:

  • Occasional use of beta-blockers for palpitations

  • No other regular medications

Social History:

  • Non-smoker

  • Moderate alcohol use

  • Regular exercise

Family History:

  • No significant cardiac history

Physical Examination

  • General: Appears fatigued but in no acute distress

  • Vital Signs: BP 120/80 mmHg, HR 90 bpm (baseline), RR 16, SpO2 98% on room air, afebrile

  • Cardiovascular: Regular rhythm with occasional irregular beats, no murmurs or gallops, no jugular venous distension (JVD)

  • Respiratory: Lungs clear to auscultation bilaterally

  • Abdomen: Soft, non-tender, no hepatosplenomegaly

  • Extremities: No edema, peripheral pulses palpable

Diagnostic Workup

  • Electrocardiogram (ECG): Shows normal sinus rhythm with occasional PACs; during an episode, ECG captures SVT at 180 bpm

  • Holter Monitor: Reveals intermittent SVT episodes, lasting a few minutes, spontaneously terminating, and interspersed with periods of normal sinus rhythm and PACs

  • Echocardiogram: Normal cardiac structure and function

  • Laboratory Tests: Normal electrolytes, thyroid function tests (TSH and free T4 within normal limits), BNP normal

Clinical Management

Acute Episode Management:

  • Vagal Maneuvers: Instruct the patient on performing the Valsalva maneuver during SVT episodes to terminate the arrhythmia potentially.

  • Pharmacologic Intervention: If vagal maneuvers are ineffective, consider the administration of adenosine under monitoring.

Long-term Management:

  • Medication: Start a regular beta-blocker (e.g., metoprolol) to help control heart rate and reduce the frequency of SVT episodes.

  • Electrophysiology Referral: Given the recurrent nature of the SVT and its impact on quality of life, refer to an electrophysiologist for further evaluation and potential catheter ablation.

  • Patient Education: Educate the patient on recognizing SVT symptoms, performing vagal maneuvers, avoiding known triggers (e.g., excessive caffeine), and adhering to medication.

Follow-Up:

  • Schedule regular follow-ups to monitor the effectiveness of treatment and adjust the management plan as needed.

  • Reassess with a Holter monitor periodically to evaluate the frequency and severity of arrhythmia episodes.

Educational Points for Blog

  • SVT Pathophysiology: Explain the mechanisms of SVT, including reentrant circuits and the role of PACs as triggers.

  • Diagnostic Approach: Highlight the importance of ECG, Holter monitoring, and echocardiography in diagnosing and assessing SVT.

  • Management Strategies: Discuss both acute and long-term management options, including non-pharmacological interventions, medications, and the role of catheter ablation.

  • Patient Education: Emphasize the role of educating patients on self-management techniques and lifestyle modifications to prevent arrhythmia episodes.

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