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Brian Rose, PA-C:
Welcome to this educational activity from GLC. I'm Brian Rose, and I'm pleased to be joined by Jennifer Carlquist. Today we're discussing consideration for accurate diagnosis of PSVT, or paroxysmal supraventricular tachycardia.

Jen, can you start us off and tell us what PSVT is, and what are some of the challenges in accurately identifying it?

Jennifer Carlquist, PA-C:
Yes, absolutely, Brian. This is a topic I love to teach about because it is confusing for practitioners because PSVT is basically an arrhythmia that is fast, usually over 150 to 160, it's narrow complex, and it's regular. And I think the confusion comes in because sometimes people will think that it is sinus tach when it is actually PSVT, or they will think it is atrial flutter with 2:1 conduction. So I think that's the challenge, right, is actually how do you figure out the arrhythmia that you're dealing with. And the other challenge is what if the patient's having these episodes when there isn't a monitor on them?

So the key really is to equip the patient with tools. So if they can get a Kardia device, if their symptoms are really infrequent, that can sometimes catch the episode. Using things like Zio patches or Holter monitors can actually catch the symptoms, but it depends on how often they're having them, really, so you have to dig deep into symptoms and the timing of them and how long they last.

I think the other challenge, Brian, is that a lot of the patients that come in, they feel anxious about these arrhythmias, and so they can often, if they don't have an arrhythmia that's been captured, they can be labeled as anxious, and this can be missed for a long time, and then patients just don't ever get the treatment they need. So that's, I think, some of the challenges that we run into.

So one of the things I look at when I'm dealing with an arrhythmia in front of me in the clinic is I'm going to look and make sure—well, first of all, if it's a high rate and they have a reason to be high, for example, they have volume loss, or they have pain, or fever, or sepsis, or COVID, or a viral illness, anything that would explain them to have a high heart rate, and they still have what appears to be a P wave, we're probably dealing with sinus tach, and we're going to notice a varying from beat to beat with sinus tach. But the PSVT is going to come in all of a sudden, sudden onset, and it's going to have no reason. It's going to come out of nowhere, and it's just going to show up and be fast and consistent.

And then the last thing I'm going to do is I'm going to make sure I'm not dealing with 2:1 atrial flutter because that can be super tricky and also come on out of the blue. So what I'll do is I'll go straight up to V1 and I'll look between the R and R, and I'll look to see if I see what is looking like a P wave between the R and R. And if I do that in V1, then there's a good chance I'm dealing with 2:1 flutter.

The other thing that's going to help me diagnose is age, because usually we're going to see 2:1 atrial flutter in our older population, and we're going to see PSVT in our younger population.

So that's kind of what I'm looking for when I meet them in clinic.

So, Brian, what do you think about monitoring? What kind of monitoring do you use, and when do you reach for it?

Brian Rose, PA-C:
Excellent question. I think a lot of it is patient symptom driven. There's different monitors that look, whether we have continuous telemetry or event monitors, and a lot of it is generated on symptom frequency. Patients that are reporting infrequent symptoms, I probably will do a much longer-term monitor for to try and capture those symptoms. Patients that may have persistent symptoms that we haven't been able to capture may be good candidates for what you said, an at-home Kardia device or even a loop recorder in those instances.

Jennifer Carlquist, PA-C:
Absolutely. It can be hard to get loop recorders covered, so another thing that I like to throw into the mix, if a patient is willing and if I can't get them a loop, if we've tried that, is an Apple Watch because—and I'll teach them in the office. I'll teach them how to record a strip. It's really easy. And then what's really cool about these devices is they can actually have it on their phone and send a PDF to us in MyChart, and I can take a look at it that way, or I can look at it when they come to the office. But I really think that's an additional tool that is often overlooked, the wearables, which can be handy.

Brian Rose, PA-C:
Absolutely. Well, thank you for joining us this evening to talk about the accurate diagnosis of PSVT and why it matters in getting the diagnosis right. We will see you next time.

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