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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 52-57

Antidepressants relieved consecutive chest pain after radiofrequency ablation: A case report and literature review


Department of Cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, China

Date of Submission01-Mar-2021
Date of Acceptance22-Apr-2021
Date of Web Publication29-Jun-2021

Correspondence Address:
Prof. Meiyan Liu
Department of Cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing 100029
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_13_21

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  Abstract 


Preexcitation symptom presents morbidity of 0.1% to 0.3% in the general population, which could lead to deadly events while accompanying arrhythmia. The classical type is Wolff-Parkinson-White (WPW) syndrome characterized as a shorter PR period, longer QRS duration, and δ wave. Radiofrequency catheter ablation (RCA) takes a vital role in treating WPW and has a high success rate. While some patients complain of consecutive chest pain after RCA, which influence their daily life severely. A 45-year-old man went to a hospital for examination because of uncomfortable palpitation. The electrocardiogram (ECG) presenting WPW syndrome (left free wall accessory pathway), then he was admitted to the hospital and scheduled for RCA. The RCA was very successful and the ECG became normal. However, after ablation, he reported consecutive chest pain, accompanied by insomnia and hypertension. No abnormal elevations of cardiac-Troponin I, myoglobin, cytokeratin, creatine kinase MB were found, and the left ventricular ejection fraction was 60%. His mental status was measured by Patient-Health Questionnaire-9, 7-item Generalized Anxiety Disorder Scale-7, Athens Insomnia Scale, indicating depressive status and anxiety status. The predominant managements involved flupentixol-melitracen and duloxetine. His chest pain, depressive, and anxiety symptoms were gradually relieved after 3-month treatment, and the drugs were slowly tapered in the 1½ years' follow-up period. Ultimately, he recovered and worked as before. This case highlights the importance of evaluating psychological status in patients with unexplained chest pain resulting from RCA and adopting antidepressants in those patients that coexist with definite depression or anxiety.

Keywords: Ablation, anxiety, chest pain, depression, Wolff-Parkinson-White


How to cite this article:
Zhang L, Liu M. Antidepressants relieved consecutive chest pain after radiofrequency ablation: A case report and literature review. Heart Mind 2021;5:52-7

How to cite this URL:
Zhang L, Liu M. Antidepressants relieved consecutive chest pain after radiofrequency ablation: A case report and literature review. Heart Mind [serial online] 2021 [cited 2022 Oct 2];5:52-7. Available from: http://www.heartmindjournal.org/text.asp?2021/5/2/52/319648




  Introduction Top


Pre-excitation symptom, defined as “sfi or some portion of the ventricular muscle is activated earlier via accessory pathways, rather than normal atrioventricular conduction system,”[1] presents morbidity of 0.1‰ to 0.3‰ in the general population, which could lead to deadly events while accompanying with arrhythmia. There are several types of pre-excitation in light of different presentations of electrocardiograms (ECG).

The classical type is Wolff-Parkinson-White (WPW) syndrome characterized as a shorter PR period, longer QRS duration, and δ wave. Radiofrequency catheter ablation (RCA) takes a vital role in treating WPW and has a high success rate. While some patients report consecutive chest pain after RCA, which influences their daily life severely.


  Case Report Top


The first stage

A 45-year-old man, at the first visit to our outpatient department, suffering chest pain for over 1 month after RCA because of WPW syndrome. One month ago, the man went to a hospital for palpitation, the ECG showed WPW syndrome [Figure 1]a. The doctor informed him of the potential risk of WPW syndrome and suggested he take radiofrequency ablation. Then he was admitted to the hospital and underwent RCA. The RCA was evaluated to be very successful: δ wave disappeared; Normal PR period; atrioventricular reentrant tachycardia (AVRT) could not be induced again. Then he was discharged from the hospital [Figure 1]b, [Figure 1]c.
Figure 1: ECG before and after RCA. (a) ECG before RCA indicating Wolff-Parkinson-White characterized by shorter PR period, longer QRS duration and δ wave; (b) Normal ECG right after RCA; (c) Normal ECG 1 day after RCA. ECG = Electrogram, RCA = Radiofrequency catheter ablation

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However, after the ablation, he felt uncomfortable, long-lasting chest pain, describing that he felt a dull pain, burning pain, numbness, and constriction in his chest, which became more severe at night or rest, consequently, he couldn't have a good sleep, and insomnia troubled him. Moreover, his blood pressure elevated much higher than ever before, even without a history of hypertension. Besides, he displayed anhedonia, always felt depressed and even hopeless, deep guilty, tired all day, and he had trouble focusing on anything. What's worse, the strong fear of death stroke him, which made him hard to breathe and lived in strong worries his life and work were badly affected.

Cardiac biomarkers, echocardiography, and ECG were detected several times, while no evidence showed acute myocardial infarction. The detection showed: Myoglobin (MYO) cytokeratin 81 U/L; creatine kinase MB 0.4 ng/ml; lactate dehydrogenase 149 U/L; cardiac-Troponin I 0.00 ng/ml; MYO 18.2 ng/ml; Echocardiography: Left ventricular ejection fraction 60%; E/A >1; ECG: Normal. Chest computed tomography Normal coronary artery without stenosis. Otherwise, he had no medical history of hypertension, neither his family. However, he complained the high blood pressure since the ablation, the clinic blood pressure detection showed: 150/105 mmHg. Gabapentin, Ibuprofen, and codeine were given to relieve his chest pain, and Metoprolol was to cure hypertension, while no benefits were achieved.

Then he visited the psychiatry department and went on psychological and angina measurements: Patient-Health Questionnaire (PHQ-9), a scale of evaluating depressive symptoms involving 9 questions, ranging from 0 to 27 scores, the higher scores indicating the severer level of depression, he got 19 scores; 7-item Generalized Anxiety Disorder Scale (GAD-7), a scale of evaluating anxiety symptoms involving 7 questions, ranging from 0 to 21 scores, the higher scores indicating the severer degree of anxiety, he got 18 scores; Athens Insomnia Scale (AIS), a scale of evaluating sleeping states involving eight questions, ranging from 0 to 24 scores, the higher scores indicating the severer degree of insomnia, he got 19 scores; Seattle Angina Questionnaire (SAQ), a scale of evaluating the chest pain and therapy satisfaction, involving 19 questions in 5 items, the higher scores indicating the better health status, Physical activity restriction 42.22 scores; Stable angina pectoris, 0 score; Frequency of angina pectoris attack, 50 scores; Satisfaction with treatment, 0 score; Cognitive degree of disease, 0 score [Figure 2]. Therefore, he was considered to have depressive and anxiety symptoms by the psychiatrist.
Figure 2: Psychological status and chest pain evaluation. (a) The depression evaluation by PHQ-9; (b) The anxiety evaluation by GAD-7; (c) The insomnia evaluation by Athens insomnia scale; (d) Chest pain evaluated by Seattle Angina Questionnaire

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The diagnoses were considered as WPW syndrome (left free wall accessory pathway); chest pain after RCA; insomnia; hypertension; depressive and anxiety symptoms.

The treatment after the first visit included: Mecobalamin 0.5 mg/tid, Oryzanol 20 mg/tid, isosorbide dinitrate 5 mg/tid, Ginkgo Biloba Dripping Pills 0.3 g/tid. Additionally, he received psychological comfort with language for 1 h in the outpatient department.

The second stage

One week after the above treatment, he felt a little better, but far from satisfied. It was time to establish an antidepressant and antianxiety treatment. Flupentixol-melitracen, Duloxetine Hydrochloride Enteric Capsules were applied for the treatment. The prescription details are shown in [Table 1]. [Table 1] presented the entire treatments from the first visit to the last visit.
Table 1: Time periods and prescriptions

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The third stage

The noteworthy curative effect appeared after 3-month treatment. The scores of PHQ-9, GAD-7, and AIS reduced significantly, and the score of the SAQ increased [Figure 2]. Then we performed mental stress (MS) tests involving mental arithmetic (MA) and mirror tracing (MT), to value whether the patient might develop mental stress induced myocardial ischemia (MSIMI). The test procedure was presented in [Figure 3]a, and the performing details and MSIMI diagnosis criteria could be seen in our published researches.[2],[3] Blood pressure, heart rate, ECG, and heart rate variability (HRV) were recorded during the test. According to the ECG criteria of MSIMI (ST depression ≥0.1 mV of three consecutive heartbeats), the patient did not develop MSIMI during the two kinds of stress [Figure 3]b, [Figure 3]c, [Figure 3]d, [Figure 3]e, [Figure 3]f. The systolic blood pressure, diastolic blood pressure, and heart rate presented an obvious rise under both MA and MT [Figure 3]g. HRV showed LF/HF ratio indicating the imbalance of sympathetic and parasympathetic nerves [Table 2].
Table 2: Heart rate variability

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Figure 3: MSIMI test: (a) The procedure of MSIMI; (b) electrocardiogram before mental stress; (c) electrocardiogram during mental arithmetic; (d) electrocardiogram during rest period; (e) electrocardiogram during mirror tracing; (f) electrocardiogram post mental stress; (g) Blood pressure and heart rate in different periods of MSIMI test

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Even though he felt much better after 3-month treatment, it was not proper time to stop medicine for he would get chest pain, uncomfortable, and higher blood pressure when psychosocial stress occurred. Therefore, the treatment continued for a longer time until he could stand life and work stress [Table 1].

The fourth stage

One year later, he did not feel any uncomfortable, even when come across with psychological stress. Therefore, the quantity of Duloxetine Hydrochloride Enteric Capsules was stepped dorm gradually. After another ½ year, the medicine was stopped completely, and he felt very well.


  Discussion Top


WPW is recognized to be the most classical type. Asymptomatic patients could live with WPW peacefully because no palpitation or other uncomfortable symptoms occur. While proper therapies must be taken when patients accompany AVRT, atrial fibrillation, which may result in sudden death.[4]

RCA has been regarded as the most common therapy in treating WPW. Compelling evidence proves its safety and the success rate could reach as high as 95%.[5] However, adverse events have also been reported, such as chest pain, endocarditis, and even death. Here, we report one of the classical cases.

The patient endured consecutive and severe chest pain after RCA, though the ablation achieved success. The unexplained chest pain may be associated with these potential pathophysiological mechanisms: First, the unhealed surgery wounds; Second, nerve injuries caused by the radiofrequency current; thirdly, myocardial ischemia induced by vessel injuries and microcirculation dysfunction; Fourth, neuroendocrine imbalance resulted from the injuries of sympathetic and parasympathetic nerves or the decrease of 5-hydroxytryptamine (5-HT), dopamine, norepinephrine in the brain; Fifth, depression and anxiety were related with his personality, the experience of RAC surgery, and the unexplained chest pain [Figure 4].
Figure 4: The mechanism of chest pain induced by radiofrequency catheter ablation

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It has been reported that unexplained chest pain always co-occurring with depression and anxiety. Moreover, the kind of chest pain could be relieved by antidepressants and anxiolytic.[6] As far as we are concerned, there is a bidirectional relationship between unexplained chest pain and psychological disorders. Panic disorder is a kind of a highly distressful yet treatable anxiety disorder. His chest pain could be caused by panic disorder. There were similar symptoms of both panic disorder and cardiovascular diseases, such as chest pain, palpitations, sweating, shortness of breath, feeling of choking, paresthesia, hot Flushes et al. Therefore, it is really hard for us to distinguish them. The panic disorder could enhance the injury of the heart, and lead to worse cardiac outcomes.[7]

In our opinion, neuroendocrine imbalance may play a vital role in the potential coexistent mechanism. After 3-month therapy, we performed an MSIMI test and recorded HRV, indicating the imbalance of sympathetic and parasympathetic nerves. Otherwise, his blood pressure increased significantly under the occurrence of chest pain and mental stress, though without a history of hypertension. Interestingly, his depressive and anxiety symptoms relieved in virtue of treating with Flupentixol-melitracen Tablets and Duloxetine Hydrochloride Enteric Capsules, implicating the lack of essential transmitters namely 5-HT.[8] Flupentixol-melitracen, contains two components including flupentixol and melitracen, functioning as antidepressants and anxiolytic.[9] By acting on the D2 receptors, Flupentixol exhibits antidepression and antianxiety treatment for increasing dopamine release to synaptic space. Meanwhile, by increasing the monoamine transmitters in synaptic space, melitracen depresses the uptake of norepinephrine and serotonin through the presynaptic membrane. Duloxetine could alleviate depressive symptoms by inhibiting serotonin as well as norepinephrine reuptake selectively.[10] Ultimately, the patient got rid of unexplained chest pain, hypertension, and psychological disorders.


  Conclusion Top


This case highlights the importance of evaluating psychological states in patients with unexplained chest pain resulting from RCA and adopting antidepressants in those patients that coexist with definite depression or anxiety. Though we have uncovered the definite effect of antidepressants in relieving chest pain after RCA, however, there is a limitation in this case: The follow-up period is not long enough to further explore the correction between antidepressants and chest pain after RCA. Therefore, we will keep following up with the patient in this case for his future health states, and more other patients with similar disease conditions.

Ethics statement

The patient has been assigned informed consent. The case report was approved by the Ethical Committee of Capital Medical University affiliated Beijing Anzhen Hospital.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

Dr. Meiyan Liu is an Executive Editor-in-Chief of Heart and Mind. The article was subject to the journal's standard procedures, with peer review handled independently of Dr. Meiyan Liu and their research groups. There are no conflicts of interest.



 
  References Top

1.
Al-Khatib SM, Pritchett EL. Clinical features of Wolff-Parkinson-White syndrome. Am Heart J 1999;138:403-13.  Back to cited text no. 1
    
2.
Liu MY, Yang Y, Zhang LJ, Pu LH, He DF, Liu JY, et al. Potential predictors for mental stress-induced myocardial ischemia in patients with coronary artery disease. Chin Med J (Engl) 2019;132:1390-9.  Back to cited text no. 2
    
3.
Zhang L, Bao Y, Wang X, Zhou Y, Tao S, Xu W, et al. A meta-analysis on the prevalence, associated factors and diagnostic methods of mental stress induced myocardial ischemia. J Transl Med 2020;18:218.  Back to cited text no. 3
    
4.
Brembilla-Perrot B, Girerd N, Sellal JM. Unresolved questions associated with the management of ventricular preexcitation syndrome. Pacing Clin Electrophysiol 2018;41:839-44.  Back to cited text no. 4
    
5.
Geczy T, Ramdat Misier NL, Szili-Torok T. Contact-force-sensing-based radiofrequency catheter ablation in paroxysmal supraventricular tachycardias (COBRA-PATH): A randomized controlled trial. Trials 2020;21:321.  Back to cited text no. 5
    
6.
Garroni D, Fragasso G. Heart or mind? Unexplained chest pain in patients with and without coronary disease. Heart Mind 2018;2:5-11.  Back to cited text no. 6
  [Full text]  
7.
Foldes-Busque G, Denis I, Poitras J, Fleet RP, Archambault P, Dionne CE. A prospective cohort study to refine and validate the panic screening score for identifying panic attacks associated with unexplained chest pain in the emergency department. BMJ Open 2013;3:e003877.  Back to cited text no. 7
    
8.
Chang L, Liu N. The safety, efficacy, and tolerability of pharmacological treatment of depression in patients with cardiovascular disease: A look at antidepressants and integrative approaches. Heart Mind 2017;1:8-16.  Back to cited text no. 8
  [Full text]  
9.
Zhou X, Zhao L, Yang P, Chen Y, Ruan XZ. The efficacy of flupentixol-melitracen in the adjuvant therapy of ulcerative colitis in the Chinese population: A meta-analysis. Gastroenterol Res Pract 2019;2019:3480732.  Back to cited text no. 9
    
10.
Kuang C, Sun Y, Li B, Fan R, Zhang J, Yao Y, et al. Preparation and evaluation of duloxetine hydrochloride enteric-coated pellets with different enteric polymers. Asian J Pharm Sci 2017;12:216-26.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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