Working Diagnosis:
Supraventricular tachycardia likely due to concealed pathway.

Treatment:
Medical treatment with antiarrhythmics was discussed, but patient preferred a curative option and elected for EP study and ablation. A left lateral accessory pathway was found and successfully ablated, revealing the ultimate diagnosis of atrioventricular reentrant tachycardia (AVRT) due to Wolff-Parkinson-White (WPW) with concealed pathway.

Outcome:
Patient was discharged home after overnight monitoring following the ablation. He was able to travel to an international training program 4 days post-ablation with his only complaint being mild groin pain. Follow-up 9 months later revealed no further episodes.

Author's Comments:
Panic attacks are the most common cause of palpitations, but cardiac arrhythmias are also common. AVRT is most commonly associated with WPW, which is typically diagnosed by a characteristic delta wave and shortened PR interval on EKG. This patient did not have either of the characteristic findings Case Photo #1 , but lack of the findings does not rule out WPW or AVRT.

The unusual observation that the patient only experienced palpitations while sitting and eating is likely due to a combination of factors. Eating increases blood flow to the abdomen, which may cause tachycardia, leading to palpitations. Increased esophageal distention during swallowing or intraabdominal/diaphragmatic pressure while eating may stimulate accessory cardiac electrical pathways. Sitting and leaning forward causes the apex of the heart to be closer to the chest wall, which can lead to an increased awareness of palpitations.

References:
Josephson, ME. Preexcitation syndromes. In: Clinical Cardiac Electrophysiology, 4th, Lippincot Williams & Wilkins, Philadelphia 2008.

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