Supraventricular Tachycardia and Catheter Ablation : Anxiety Levels and Patient Perceptions

Aim: To investigate anxiety levels and patient perception associated with supraventricular tachycardia (SVT); investigate anxiety levels and patient perception preand postradiofrequency catheter ablation (RFCA); and explore any association between anxiety and patient perception with patient age and gender. Design: Follow-up quantitative and qualitative cohort study. 141 patients in a tertiary centre in Scotland who underwent an electrophysiological study and RFCA for atrioventricular nodal reentrant tachycardia, atrioventricular re-entrant tachycardia or atrial tachycardia between 2009 and 2012 were enrolled. 59 (41.8%) were male; mean age at follow-up was 50 years. Interventions: Follow-up by structured phone questionnaire; mean follow-up period was 14 months. Main outcome measures: Anxiety level and patient perception during index episode, and anxiety level before and after RFCA. Results: During index episode, median patient anxiety, on a scale of 0–10, was 8. Anxiety was not associated with gender (p = 0.07). Patients in the lowest and highest anxiety groups tended to be older (mean 54.5 and 44.4 years respectively) compared with those in the middle 2 groups (mean 34.1 and 35.6 years). There was an association between anxiety and age (p = 0.039). 45 (32.0%) participants thought they were having a heart attack or dying. Before RFCA, median anxiety level was 7. 55 (39.0%) patients were afraid of complications, 21 (14.9%) patients feared being awake during RFCA. After RFCA, median anxiety was 2.5. Conclusions: Anxiety is a common accompaniment to SVT that may lead to greater preprocedural anxiety. Exploring this link may allow reduction of anxiety via better psychopharmacological intervention, education, and preprocedural counselling. Copyright Royal Medical Society. All rights reserved. The copyright is retained by the author and the Royal Medical Society, except where explicitly otherwise stated. Scans have been produced by the Digital Imaging Unit at Edinburgh University Library. Res Medica is supported by the University of Edinburgh’s Journal Hosting Service: http://journals.ed.ac.uk ISSN: 2051-7580 (Online) ISBN: 0482-3206 (Print) Res Medica is published by the Royal Medical Society, 5/5 Bristo Square, Edinburgh, EH8 9AL Res Medica, 2014, 22(1):2-14. doi:10.2218/resmedica.v22i1.817 Res Medica 2014, Volume 22, Issue 1 El-Medany, A. & Grubb, NR. Supraventricular Tachycardia and Catheter Ablation: Anxiety Levels and Patient Perceptions. Res Medica 2014, 22(1), pp. 2-13. doi:10.2218/resmedica.v22i1.817 2 Supraventricular Tachycardia and Catheter Ablation: Anxiety Levels and Patient Perceptions


Introduction
Supraventricular tachycardia (SVT) encompasses a group of common paroxysmal tachyarrhythmias.SVT occurs in all age groups, and its mechanism varies depending on patient demographics. 1evalence is around 2.25 per 1000 in the general population. 2 Atrioventricular nodal re-entrant tachycardia (AVNRT) is the commonest cause of paroxysmal SVT, accounting for 50-60% of diagnoses. 3,4It is more prevalent in young females. 5The AV node usually has a single conducting pathway whereby impulses travel to reach the bundle of His and cause contraction of the ventricles of the heart.
Dual conduction pathways may coexist in some individuals and premature atrial impulses travelling along the secondary pathway may trigger episodes of AVNRT.
[8] Presentation of SVT can range from an asymptomatic presentation and anxiety to shortness of breath, syncope, and chest pain.Palpitations are present in 96% of presentations. 9,10Although SVT is not usually life threatening, many patients suffer recurrent symptoms that have a significant impact on their quality of life.Many have symptoms for a prolonged period of time before diagnosis.[13] Radiofrequency catheter ablation (RFCA) is the first-line therapy for many SVTs, usually performed as a day-case procedure using conscious sedation.The efficacy of RFCA exceeds that of medical therapy, with success rates of around 95%. 14 The procedure involves insertion of an ablation catheter, usually via the femoral vein, allowing for focal ablation of a critical component of the arrhythmic mechanismsuch as an accessory pathway -using heat generated from high frequency alternating current.

Hypothesis
We hypothesize that 1) patients with SVT experience high levels of anxiety during their index episode and many believe they are experiencing a cardiac event;

Follow-up and data collection
The mean follow-up period was 14 months The ANOVA test was used to determine if there was any significance between age or anxiety level and patients' perception of their index episode.Thoughts were divided into 2 categories: "dangerous" and "benign", and compared with anxiety levels.
The mean anxiety experienced was compared with patients' thoughts prior to RFCA.

Anxiety during index episode
Out of 141 patients, median anxiety during index episode was 8. Anxiety was divided into 4 groups (Figure 1).Results showed 26 (44.1%) of males and 48 (58.5%) of females experienced severe anxiety (≥ 8) during their index episode.There was no significant association between anxiety and gender (p = 0.07) with a similar distribution of males and females amongst anxiety groups.There was a significant association between age and anxiety during the first episode.
Older patients showed greater anxiety (p = 0.028).Patients that showed no anxiety during the index episode were excluded from this statistical test as the sample size was too small.(n = 2) (Figures 1&2).
Patient perceptions during index episode 45 (32.0%) participants thought they were having a heart attack or dying (Figure 3).Of these patients, 43 (95.6%) had an anxiety rating in the severe category (8-10).
The mean anxiety level for patients who experienced chest pain during their index episode was 7.7, while patients who did not experience chest pain had a mean anxiety of 6.8.15 out of 28 patients (53.6%) who experienced chest pain during their index episode thought they were dying or having a heart attack.
There was a significant association between age at first episode and patient perception, with older patients tending to think they were having a heart attack or dying and younger patients regarding their index episode as benign palpitation or as a result of overexertion (p = 0.004) (Figure 4).The "other" category included indigestion, menopause, medication, overexcitement, pregnancy, and fatigue as perceived causes of the index episode.There was a significant association between anxiety level and patient perception of their index episode (p <0.001).
Patients showed a higher anxiety level if they thought they were having a heart attack or dying (Figure 4).

Patient anxiety pre-and post-RFCA
Prior to RFCA, median patient anxiety was 7. The most common cause of concern and the greatest median subjective anxiety score prior to RFCA was due to fear of complications.55 (39.0%) patients were afraid of complications, while 21 (14.9%)patients noted a fear of being awake during the procedure (Figure 5).The median anxiety level after RFCA was 2.5.
The "other" category included fear of hospital, needle phobias, concern over the induction of palpitation, and waiting a long period prior to the procedure.

Discussion
Anxiety affects a large proportion of SVT patients.Of the 141 patients interviewed in this study, 74 (52.5%) experienced severe anxiety, with a reported anxiety level at index episode of 8 or above.Anxiety levels were not affected by gender (p = 0.07), which is surprising as there is a higher prevalence of anxiety disorders in females, 12 although none of the patients in this study had any known pre-existing psychiatric disorders.Moreover, female patients were more likely to attribute their palpitation to excitement, medication, or menopause, and this may be the reason why the mean anxiety level is similar between the genders as the palpitation was perceived to be a 'natural' event.Current literature states that males perceive cardiac disease more negatively and thus portray more anxiety and depressive symptoms. 18ere was a significant association between anxiety during the index attack and patient age, as hypothesized (p = 0.028).Older patients reported higher anxiety levels whereas younger patients reported mild to moderate anxiety throughout their first attack.These variations may be due to individual symptom perception, or pre- The median anxiety level prior to RFCA was highest in patients afraid of complications and of being awake during the procedure.
Lack of information and fear of potential complications are known to cause high levels of anxiety. 22,23However, it could be argued that this is the case for any invasive procedure and not RFCA in particular.
There Previous research has suggested including discussions of previous patient experiences or reassurance from the clinician prior to RFCA to alleviate patient anxiety. 24The idea of catheters entering the heart and ablating tissue will seem bizarre to patients, and the complexity of RFCA may require a more detailed explanation from the physician in order to alleviate patients' health concerns in comparison with other invasive procedures.
The significant decrease in patient anxiety from a mean of 7 to 2.5 highlights the efficacy of RFCA.Anxiety levels after RFCA have previously been characterized, with a dramatic improvement in quality of life and anxiety levels. 25Invasive treatment of SVT may result in reduction of anxiety due to the placebo effect or due to ablationinduced changes in the arrhythmia.Studies looking at the placebo effect of other invasive cardiac procedures show that they significantly alter the perception of preexisting symptoms and reduce anxiety 26 and this is probably true for ablation procedures for atrial fibrillation 27,28 despite recurrences of symptoms.Further studies are needed to clarify this issue.Anxiety levels after ablation should be measured at a set time after the procedure, rather than immediately after or at arbitrary times, to allow for valid comparison between patients.

Implications for practice and policy
Anxiety is an important cause of morbidity and increased utilization of medical care.It is important for medical students to appreciate the impact that psychopathology can have on pre-existing disease and its prognostic contribution to cardiovascular disease. 29Identifying a demographic pattern in patients who present with severe anxiety after SVT will allow for more efficient psychopharmacological intervention.

Limitations
Telephone interview was selected as the best method for collecting data compared with mailed questionnaires.The expected response rate was greater, therefore reducing response bias.Communicating over the phone allowed the interviewer to clarify any misinterpretations of the participants, thus improving the reliability of the results. 30ere was risk of recall bias with over-or under-reporting of anxiety levels.Patients This study provides a basis for further study.
The ANOVA test was used in this study to determine associations between patient anxiety and patient perceptions during their index episode.For this to be possible, perceptions had to be divided into 2 categories.The division of patients' thoughts into binary values -"dangerous" and "benign" -is potentially problematic.
This could be avoided in further studies by simplifying the question regarding perceptions and asking patients if they felt that they needed to go to the hospital or not, then determining an association with anxiety between the 2 groups using the Mann-Whitney test.

Conclusion
The psychological health of patients is an important factor to take into account as anxiety and individual disease perception can have an impact on the severity of symptoms. 31Anxiety is a common accompaniment to SVT and is more prevalent in older patients, hence supporting this study's hypothesis.However, there seems to be no association between gender and anxiety.Many patients believe that they are having a heart attack or dying during their index episode.The perceived complexity of RFCA commonly elicits periprocedural anxiety in patients, suggesting that this is a factor which could be targeted by better counselling and education of patients at the time of referral and review and prior to their procedure.
RFCA can significantly reduce patient anxiety.

Learning Points
What is already known?
 SVT is a common tachyarrhythmia that causes anxiety in many patients.
 Misinterpretation of episodes is common and many SVTs are misdiagnosed as panic attacks.
 Catheter ablation is the first-line treatment for SVTs and significantly reduces anxiety levels in patients.

What does this study add?
 This study explores patients' anxiety during their index episode of SVT and provides details of patients' perceptions of their first attacks.
 As anxiety is a common problem associated with SVT, exploring this aspect will hopefully lead to cardiologists providing more counselling and improving patient education during the time of referral and review and prior to the catheter ablation procedure.
 Reducing anxiety in SVT patients will drastically lessen the severity of physical symptoms and improve quality of life.

(range 3 . 2 -
39.1 months).Telephone interviews lasted an average of 5 minutes and consisted of a structured clinical interview (see Appendix for clinical questionnaire).Questions were designed to explore patient anxiety levels during their index episode, and before and after RFCA, using a subjective scale of 0-10 (where 0 indicates no anxiety and 10 indicates maximum anxiety).Patient perceptions of of SVT and thoughts prior to RFCA were investigated using open-ended questions.Patients were encouraged to provide further comments about their perceptions and concerns about their index episode and RFCA procedure.Patients were also encouraged to provide comments about the symptoms experienced during their index episode such as chest pain, shortness of breath, or dizziness.Statistical analysisStatistical analysis was conducted using SPSS software.Anxiety level during the index episode was divided into 4 categories:(1) no anxiety (0); (2) mild anxiety (1-4); (3) moderate anxiety (5-7); and (4) severe anxiety(8-10).Any association between anxiety level during index episode and the gender or age was analysed using the Mann-Whitney test.Gender was divided into 2 groups: male and female.Age was divided arbitrarily into 2 groups: "older" and "younger", separated by the median age of 52.Anxiety ratings were treated as ordinal data (values existing on an arbitrary scale) and ranked.The Mann-Whitney test was then used to assess the null hypothesis: that there would be no variation in anxiety between genders or age.The most common answers regarding perceptions during the index episode were grouped into 6 categories and less common answers were categorized under "other".

Figure 1 .
Figure 1.Proportion of male and female patients experiencing anxiety during their index episode of SVT.Participants were categorized into 4 groups depending on their anxiety level.
Figure 3.What patients thought was happening during their index episode.The 'other' category included indigestion, menopause, medication, over excitement, pregnancy and fatigue as perceived causes of index episode.

Figure 2 .
Figure 2. Mean age of participants during index episode of SVT, and their corresponding anxiety level.Participants have been categorized into 3 groups, depending on the level of anxiety experienced.

Figure 4 .Figure 5 .
Figure 4. Mean patient age at index episode and the mean anxiety level associated with what patients thought was happening during their index episode.
may not accurately remember how anxious they were during their index episode and thus may have given inaccurate reports of their anxiety.To reduce bias, the interviewer was trained and the same interviewer was used in each case.The use of a subjective anxiety scale is a potential source of bias and is not the most reliable way of measuring anxiety, as it can vary depending on the individual and situation and, therefore, lead to unreliable results.Furthermore, results obtained from a subjective scale can be difficult to interpret because of the ordinal nature of the collected data.The use of a subjective scale, however, meant that a larger sample size was recruited.Furthermore, the high participation rate -141 out of 148 (95.3%)supports the use of a subjective scale due to its simplicity.Nonetheless, this study could be repeated using official psychiatric questionnaires such as the Generalized Anxiety Disorder assessment (GAD 7) and Social Anxiety Questionnaire for Adults (SAQ-A30) to allow for more valid results.

( 2 )
Structured Clinical InterviewHow old were you when you had your first episode?What was the first thing you thought when palpitation started?How anxious did you feel during your first attack?(score of 0-10; 0 being not anxious at all and 10 being the most anxious you could be) you ever get palpitation when you are doing nothing/ no obvious trigger?you before your ablation?(0-10) What were you worried about?How anxious were you after the procedure?(0-10) Did you experience any pain at any point during the procedure?(Y/N) When?Pain (0-10) Did you feel breathless at all during the procedure?(Y/N) Did you feel dizzy at all? (Y/N) Any palpitation since your ablation?(Y/N)