St. John’s Wort-Induced Supraventricular Tachycardia 2021 Kristy A Fisher.pdf

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ReportDOI:
’sWort-InducedSupraventricular
Tachycardia
,PoonamPatel2,SamerAbualula3,LivaskyConcepion3
,AventuraHospitalandMedicalCenter,Aventura,,NovaSoutheasternUniversityDr.
,Davie,,AventuraHospitalandMedical
Center,Aventura,USA
Correspondingauthor:,kristy.******@
Abstract
’swort,anon-FDA-approvedover-the-counter(OTC)herbalsupplementwithantidepressant
activityknownasHypericumperforatum,hasbeenfoundtoinducesupraventriculartachycardia(SVT)inthe
absenceofanyunderlyingstructuralcardiacabnormalityorknownmedicalhistoryviacurrentlyunclear
,theauthorspresentacaseofa33-year-oldfemalewho
’swortforthe
treatmentofdepression,,the
’
’swort-

intheknowledgeandunderstandingofthecausativemechanismandtoidentifythosepatientswhoareat
potentiallyheightenedrisksofsuchmanifestations.
Categories:Cardiology,InternalMedicine,Psychiatry
Keywords:cyp450,svt,internalmedicine,consultationliaisonpsychiatry,’swort,supraventricular
tachycardia,hypericumperforatum,depression,anxiety,palpitations
Introduction
’swortinthemanagementofdepression
Hypericumperforatumhasbeenwidelyusedforcenturiesthroughouttraditionalmedicineasanover-the-
counter(OTC)agenttotreatdepressionduetoitsefficacyinmildtomoderatedepression,alongwithits
relativelysafeside-effectprofile[1],whichincludeshepatotoxicity,cardiovascularcompromise,
gastrointestinalupset,inductionofmania,dizziness,confusion,fatigue,anxiety,andphotosensitivity,
alongwithmajordruginteractionsduetoinductionoftheCYP3A4and2Cpenzymesofthecytochrome
P450system[1,2].Theactiveprincipleaccountablefortheantidepressanteffectsisunknown,butsuspected
agentsincludehypericin,pseudohypericin,andhyperforin[2].Themechanismofactionresponsibleforthe
’swortincludesinhibitionoftheserotonin,norepinephrine,and
Reviewbegan03/23/2021
dopaminereuptake,activationoftransientreceptorpotentialC6channelswithpossibleinfluenceof
Reviewended03/30/2021
Published04/07/2021monoamineuptake(specificallyhyperforin),stimulationofthedevelopmentandfunctionof
oligodendrocytes,andsuppressionofvoltage-dependentcalciumchannelandmitogen-activatedprotein
©Copyright2021
kinaseresultinginreleaseofglutamate(specificallyhypericin)[3-7].

distributedunderthetermsofthe
CreativeCommonsAttributionLicense
CC-.,whichpermitsunrestrictedSupraventriculartachycardia
use,distribution,andreproductioninanySupraventriculartachycardia(SVT),abroadtermencompassingmanyheartarrhythmias,isanabnormally
medium,providedtheoriginalauthorand
fastheartbeatthatarisesintheatrialtissueoratrioventricularnode(AV),andthemost
sourcearecredited.
commonSVT(excludingatrialfibrillationandatrialflutter),isAV-nodalreentranttachycardia(AVNRT).
CausationisviareentrantconductionwithintheAVnode,utilizingboththefastandtheslowpathways.
Electrocardiogram(ECG)usuallyindicatestheabsenceofaPwaveprecedingtheQRScomplex;thePwave
canappearasapseudoR’waveinleadV1andpseudoS’
physicalmaneuvers(vagalstimulus)

continuesorthepatientpreferstoavoidlong-termmedicaltherapy,catheterablationiswarranted,which
carriesa1%riskofAVnodalinjuryrequiringpacemakerimplantation[8].
CasePresentation
Thepatientisa33-year-oldfemalewithareportedhistoryofdepressionforadurationofonemonth,who


inmarriagecounselingthreeweekspriortopresentation,’swortata
-initiationofpharmacologictreatment,thepatientreported
Howtocitethisarticle
FisherKA,PatelP,AbualulaS,etal.(April07,2021)’sWort-(4):

sweating,insomnia,andfrequentepisodesofpalpitationsbothatrestandwithexertion,whichexhibited
persistenceoflessthanoneminutewithspontaneousresolution.
Atpresentation,thepatientwasawake,alert,andoriented,withapalpablecarotidpulseandheartrate(HR)
of150-,shortnessofbreath,dizziness,,
aValsalvaandcarotidarterymassagewasperformedsimultaneously,withresultantacuteabruptionof
(ED),anotherepisodeoccurredwithsimilar
presentation(HR:150-160bpm;bloodpressure(BP):110/68mmHg;oxygensaturationandrespiratoryrate
withinnormallimits;deniedchestpain,shortnessofbreath,orpresyncopalsymptoms).ECGrevealedSVT
withHR148bpm,withnoprecedingPwave,pseudoR’onV1,andpseudodeepS’intheinferiorleads.
Physicalexamwasdeemedunremarkable,asidefromtachycardiaandreportedanxiety,whichthepatient
,includingcompleteblood
count(CBC)andcomprehensivemetabolicpanel(CMP),withnegativetoxicologyscreen,undetectable
bloodalcohollevel,
attemptedValsalvamaneuver,therhythmconvertedtosinusrhythm(SR)withouttheadministrationof
,withascheduledelectrophysiologist(EP)
outpatientfollow-up.
UponEPfollow-up,repeatelectrolyteswerenormal,withatransthoracicechocardiogram(TTE)revealing
normalejectionfraction(EF)at60-65%,nowallmotionabnormality,normalcardiacvalves,normalcardiac
structures,anddimensionwithrightventricularsystolicpressure(RVSP)
’swortherbalsupplement,withstrictobservationandnomedicalor
,
persistinganywherefrom30secondstofiveminutes,witheitherresolutionspontaneouslyorwiththe
personalperformanceofthemodifiedValsalvamaneuver(strainfor15secondsinthesemi-recumbent
positionfollowedbysupinerepositioningwith15secondsofpassivelegraiseat45-degreeangle).After
’swortherbalsupplement,completeresolutionwasreported.
Discussion
Depressionisawidelyundiagnosedanduntreatedmedicalconditioncharacterizedbylowmood,anhedonia,
andfatiguethatcanaffectapatient’sthoughts,behavior,motivation,feelings,andoverallhealth[9].
Depressedmoodischaracterizedasasymptomcontributingtomooddisorders,suchasmajordepressive
disorder(MDD),dysthymia,andbipolardisorder,andmayevenmanifestasaresultofanormalreactionto
,depressionisamajorcontributortoworldwidedisability,withanestimated350
millionpeopleaffected[10].Ofthose,43%sufferingfromseveredepressionintheUSAreporthaving
dysfunctionsintheirdailylife[11].Selectiveserotoninreuptakeinhibitors(SSRIs)areconsideredthefirst
(FDA)-
approvedinthemanagementofdepressivedisorders,’swortasamonotherapyhasbeenfoundtobe
superiortoplacebo[1],withademonstrationofcomparableefficacytoSSRIsinthetreatmentofmildto
moderatedepression[12].Thechronicity,recurrentnature,andrequiredlong-termtreatmentofdepression
,alongwiththe
cost-efficacy,availability,andrelativelysafeside-’swort,leadspatientstopreferit
asatreatmentoverSSRIsinthemanagementofdepression[13].
’swortiscurrentlyconsideredaseitheracomplementary,augmenting,oralternativemedicineby
manypractitioners,includinggeneralpractitioners(GP),manyarestillhesitant
“off-
label”andoftentimes,duetoitseasyaccessibilityoverthecounterandmultipleavailableformulations,
patientsdonotalwaysdiscloseitsusetotheirdoctor[14].Inastudyconductedamongpsychiatrists,almost
'swort,with25%of
“off-label”
medicineinthegeneralpopulation,participatingphysiciansreportedthattheirpatientsshouldbeeducated
'swortandinformedofitssideeffectprofileanddrug-to-druginteractions[15].
'sworthasarelativelylowsideeffectprofilewhenusedinisolation,themajorityofadverse
reactionswerefoundtoarisefromdrug-to-(SS)in
'swortalongwithpharmaceuticalantidepressantshavebeendocumented
[16].SSisamedication-inducedconditionresultingfromexcessivestimulationofthecentralandperipheral
synaptic5-HT2Aserotoninreceptors,withsubsequentpotentiallylife-threateningconsequencesdueto

varietyofpossiblyexhibitedsymptoms(rangingfrommild,flu-likesymptomstoseverecardiovascular
collapseanddeath),diagnosisisclinically
basedonthecontingenttriadofalteredmentalstatus,autonomichyperactivity,andneuromuscular
abnormalitiesinpatientsexposedtomedicationswiththepropensitytoincreasetheeffectsofserotonin
[17].'sworthasbeenshowntomodulatethelevelof
neurotransmitters,suchasserotonin,byweakeningtheactivityofcatechol-O-methyltransferase,thus
reducingtheuptakeofserotonin[16].However,’swortasa
(4):
monotherapyinthemanagementofdepression.
Whentreatingpatientswithdepression,itisimperativetoalsoconsiderco-existingpsychiatric(most
commonly,anxietydisorders)andmedicalcomorbidities,whichcanleadtodifficultyintheproper
evaluation/examination,diagnosis,andtreatment[18].Furthermore,psychiatricconditionsmaymimic

,specialistsgenerallytreattheacutelyoccurring
symptomsspecifictotheirspecialtybeforeaddressingthefullrangeofconcerns,makingitdifficultto

cardiologistsandpsychiatristswhenfacedwithdeterminingthecausativechronologyofpanicattacks
(episodesofpalpitations,chestpain,dizziness,light-headedness,difficultybreathing,numbnessand
tinglinginhands,flushes,orchills)(PVST).
Forexample,onestudydiscussingthepathophysiologyofthissharedsymptomatologyhypothesizedthat

postulationmanifestedfromthefindingsofPVSTastherootcauseof“panicattacks”ratherthanthe
“panicattacks”followingcatheter
ablationinpatientspreviouslydiagnosedwithpanicdisorder[19].Thoughthismayprovidesomeinsight
anddirectionforpractitioners,furtherinvestigationisneededinregardstotheactualprevalenceofSVTas
theunderlyingmechanismofpanicattacksinordertoproperlyguideappropriatediagnosisand
treatment/management.
Conclusions
’

understandingofthecausativemechanismandtoidentifythosepatien