The Psych Consult: Racing Heart, Wrong Diagnosis. Telling SVT and POTS Apart From Panic

THE PSYCH CONSULT: SECOND OPINION

In the inaugural episode of “The Psych Consult: Second Opinion,” host Claire Brandon, MD, a consultation-liaison psychiatrist and founder and medical director of Whole Body Psychiatry in New York City, spoke with interventional cardiologist Lara Oboler, MD, about how supraventricular tachycardia (SVT) and postural orthostatic tachycardia syndrome (POTS) can mimic panic disorder, and how clinicians in both specialties can tell the difference.

Brandon opened with a composite case drawn from her practice: a 28-year-old woman with sudden-onset heart pounding, chest tightness, shortness of breath, and a wave of dread who was repeatedly discharged from the emergency department with a diagnosis of panic disorder after normal exams and electrocardiograms (EKGs). By the time she reached psychiatry, she had developed genuine anticipatory anxiety around her symptoms, but an ambulatory event monitor eventually captured a heart rate of 180 beats per minute (bpm) during a symptomatic episode.

For Oboler, a heart rate that high, paired with an abrupt on-and-off pattern, is a signal to keep looking. "That, for me, as a cardiologist, is a diagnosis of exclusion," she said, noting that panic disorder more typically produces heart rates in the 100 to 150 bpm range. She also flagged whether P waves are present on monitoring: sinus tachycardia, characteristic of panic, shows P waves, while SVT typically does not.¹ Both physicians agreed that fear and its accompanying catecholamine surge occur regardless of the underlying cause and cannot, on their own, distinguish panic from arrhythmia.

Bedside and At-Home Clues

Oboler outlined questions and maneuvers clinicians and patients can use ahead of formal testing: whether the heart rate ramps up gradually or starts abruptly, whether numbness or tingling accompany the episode (more consistent with panic), and whether vagal maneuvers such as bearing down or carotid massage terminate it. Those maneuvers, she said, will break an SVT episode but not a panic attack or other arrhythmias, making them a practical diagnostic clue. A resting 12-lead EKG, she cautioned, "is a 3-second snapshot" and will miss a paroxysmal rhythm if the patient is asymptomatic at the time of testing; ambulatory or event monitoring is often needed. Baseline labs to rule out thyroid dysfunction and anemia round out the workup before a panic disorder diagnosis is confirmed.

Both physicians flagged red flags warranting emergency evaluation: prolonged rapid heart rate accompanied by dyspnea, dizziness, or chest pain, or any sign of hemodynamic instability. Oboler said patients who cannot terminate an SVT episode with vagal maneuvers, or who become symptomatic, should go to the emergency department rather than urgent care, since only the ED can administer adenosine or other rhythm-converting treatment.

Wearables and an Office-Based POTS Screen

The conversation also covered consumer wearables. Patients increasingly bring their own heart-rate and rhythm data from devices such as the Apple Watch, which Oboler said can be reassuring but also generates false positives for atrial fibrillation because the underlying algorithm is tuned to overcall rather than miss an event. For suspected POTS, Oboler described an in-office alternative to formal tilt-table testing: having a patient stand for 10 minutes while monitoring heart rate and blood pressure. A heart-rate increase of 30 bpm or more with stable blood pressure is suggestive of POTS.² Because beta-blockers are a POTS treatment, she added, clinicians should know if a patient is taking propranolol, sometimes used off-label in psychiatry for performance anxiety, before autonomic testing, since it can blunt the heart-rate response without stopping the underlying SVT, which she described as "an electrical issue" that beta-blockade "really probably won't interfere with too much."

Treating Both Tracks

Brandon and Oboler agreed that treating the underlying arrhythmia does not eliminate the anxiety that develops around it. In the composite case, the patient underwent catheter ablation for SVT but continued to experience panic symptoms afterward, a hypervigilant, conditioned fear response to normal bodily sensations. First-line psychiatric treatment was an SSRI, which Oboler said she considers safe in cardiac patients outside of QTc-prolongation concerns associated mainly with higher-dose citalopram. "Anxiety is a real medical problem," Oboler said. "Feeling good about yourself and feeling good day to day is just as important as having a strong heart." She added that ablation itself can be a reasonable option when SVT-triggered panic attacks are frequent enough to meaningfully impair quality of life.

Brandon noted that some patients develop symptoms consistent with posttraumatic stress after a cardiac event, since a sense of impending death is part of the diagnostic criteria for PTSD, and said psychiatric follow-up should run in parallel with cardiac care rather than only after a cardiac diagnosis is settled. Oboler agreed, adding that patients recovering from stent placement or open-heart surgery are often unprepared for postprocedural depression or anxiety, and said "after-care" conversations need to address this directly, alongside clearer communication about when a patient has been safely discharged from a specialist's care.

Dr Brandon is the founder and medical director of Whole Body Psychiatry. She is dual board-certified in adult psychiatry and consultation-liaison psychiatry, and specializes in gut-brain health.

Dr Oboler is a clinical cardiologist who has been practicing for 20 years. She is triple-boarded, co-chairs the GW Medical School Board of Advisors, and sits on the President’s Council at Tufts University.

References

1. Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Unrecognized paroxysmal supraventricular tachycardia. Potential for misdiagnosis as panic disorder. Arch Intern Med. 1997;157(5):537-543.

2. Sheldon RS, Grubb BP 2nd, Olshansky B, et al. 2015 Heart Rhythm Society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015;12(6):e41-e63.