What history should I take when evaluating a patient with tachycardia (rapid heart rate) in a psychiatric setting?

History Taking for Tachycardia in a Psychiatric Patient

When evaluating tachycardia in a psychiatric patient, immediately obtain a structured cardiac risk assessment focusing on medication history (especially psychotropics and QT-prolonging drugs), cardiac symptoms, family history of sudden cardiac death, and medical comorbidities before assuming a benign etiology. 1

Immediate Assessment Priorities

Vital Signs and Clinical Context

• Document the heart rate, blood pressure, temperature, and respiratory rate immediately, as fever, hypertension, or hypotension suggest organic causes requiring extensive workup 2, 3
• Assess for altered mental status, disorientation, or confusion, which indicates possible delirium and necessitates comprehensive metabolic evaluation 1, 2
• Evaluate for focal neurological deficits or signs of cerebrovascular disease, as these mandate broader evaluation regardless of psychiatric presentation 1, 2

Medication History (Critical Priority)

Current Psychotropic Medications

• Document all current and recent psychotropic medications with specific doses and duration of treatment, as antipsychotics are strongly associated with severe tachycardia (odds ratio 4.09) 1, 4
• Identify all QT-prolonging medications, including antipsychotics (especially clozapine, ziprasidone, thioridazine), antidepressants, and other psychiatric drugs 1, 5
• Ask about recent dose increases or medication changes, as tachycardia often emerges during titration or at steady-state 6, 5
• Document anticholinergic medication use, which significantly contributes to tachycardia risk 4

Drug Interactions and Polypharmacy

• List all medications including over-the-counter drugs, herbal supplements, and vitamins, as CYP-system inhibitors (e.g., verapamil) can increase pro-arrhythmic risk 1
• Identify potassium-wasting drugs (diuretics), which increase arrhythmia risk through electrolyte disturbances 1
• Document any medications known to prolong QT interval beyond psychotropics 1

Cardiac History

Structural Heart Disease

• Ask about history of coronary artery disease, including prior myocardial infarction, CABG, PCI, documented stenosis >50%, positive stress tests, or angina 1
• Document any history of cardiomyopathy (hypertrophic, dilated, or left ventricular dysfunction with ejection fraction <40%) 1
• Inquire about congenital heart disease and any prior repairs 1
• Ask about valvular heart disease, particularly aortic stenosis or hypertrophic cardiomyopathy, as syncope with SVT may indicate these conditions 1

Arrhythmia History

• Document any prior supraventricular tachycardias, including atrial fibrillation, atrial flutter, atrial tachycardia, AV nodal re-entrant tachycardia, or accessory pathway-mediated tachycardias 1
• Ask about history of ventricular arrhythmias (ventricular tachycardia or fibrillation requiring cardioversion or antiarrhythmic drugs) 1
• Inquire about bradyarrhythmias, including sick sinus syndrome, sinus bradycardia, or AV block 1
• Document any history of arrhythmogenic syndromes: Brugada syndrome, long QT syndrome, Wolff-Parkinson-White syndrome, or arrhythmogenic right ventricular cardiomyopathy 1

Device History

• Ask about pacemaker or implantable cardioverter-defibrillator (ICD) placement, including type, indication, and capability for burst pacing or antitachycardia pacing 1
• Document any prior catheter ablation procedures and their indications 1

Cardiac Symptom Characterization

Tachycardia Pattern

• Determine if palpitations are regular or irregular, as irregular rhythms suggest atrial fibrillation, multifocal atrial tachycardia, or premature beats 1, 7
• Ask about onset and termination characteristics: abrupt onset/termination suggests paroxysmal supraventricular tachycardia (AVRT or AVNRT), while gradual acceleration suggests sinus tachycardia 1, 7
• Document frequency, duration, and number of episodes to establish pattern 1
• Ask if vagal maneuvers (Valsalva, carotid massage) terminate episodes, which suggests re-entrant tachycardia involving AV nodal tissue 1, 7

Associated Symptoms

• Ask about chest pain, dyspnea, lightheadedness, presyncope, or syncope during episodes 1, 7
• Document polyuria during or after episodes, which suggests sustained supraventricular arrhythmia from atrial natriuretic peptide release 1
• Inquire about palpitations described as "pulsation in the neck", characteristic of supraventricular tachycardia 7
• Ask about diaphoresis during episodes 8

Syncope Evaluation

• If syncope occurred, determine timing: syncope just after tachycardia initiation or with prolonged pause after termination suggests SVT 1
• Syncope with rapid heart rate warrants evaluation for accessory pathway (Wolff-Parkinson-White) with atrial fibrillation, which requires expedient cardiology referral 1, 7

Family History

• Ask specifically about family history of sudden cardiac death, particularly in young relatives, as this suggests inherited arrhythmogenic syndromes 1
• Document family history of long QT syndrome, Brugada syndrome, or other inherited cardiac conditions 1
• Inquire about family history of cardiomyopathy 1

Medical Comorbidities

Cardiovascular Risk Factors

• Document history of hypertension, as heart disease is more prevalent in psychiatric patients 1
• Ask about diabetes mellitus and method of control (none, diet, oral agents, insulin) 1
• Inquire about hyperlipidemia and smoking history 1

Other Medical Conditions

• Document thyroid disease history, as thyroid dysfunction can cause tachycardia 1
• Ask about chronic lung disease, particularly if irregular palpitations suggest multifocal atrial tachycardia 1
• Inquire about chronic kidney disease, which affects electrolyte balance and drug metabolism 1
• Document history of cerebrovascular disease, including stroke or TIA 1
• Ask about infectious diseases (HIV, hepatitis C), particularly if risk factors present 1, 2

Recent Medical Events

• Ask about recent infections or fever, as these are common triggers for tachycardia in psychiatric patients 4
• Document any recent head trauma or neurological symptoms 1
• Inquire about recent surgeries or procedures 1

Substance Use History

• Document current and recent use of tobacco, alcohol, marijuana, cocaine, heroin, hallucinogens, and stimulants, as substance use is highly prevalent in psychiatric populations and directly causes tachycardia 1
• Ask about misuse of prescribed medications or over-the-counter stimulants 1
• Inquire about recent changes in substance use patterns, including withdrawal states 1
• Document caffeine and energy drink consumption 1

Psychiatric History Context

• Document primary psychiatric diagnosis (schizophrenia, bipolar disorder, depression, anxiety) 1
• Ask about prior psychiatric hospitalizations and emergency department visits, as these patients often have complex medication histories 1
• Inquire about treatment adherence, as non-adherence followed by resumption can trigger arrhythmias 1
• Document whether this is a new psychiatric presentation or established diagnosis, as first presentations require more extensive medical workup 1, 2

High-Risk Population Identification

Recognize that elderly psychiatric patients, those without prior psychiatric history, patients with substance abuse, and those with new medical complaints require lower thresholds for extensive cardiac evaluation 1, 2, 3. These populations have dramatically higher rates of organic causes for tachycardia and sudden cardiac death risk 1.

Critical Pitfalls to Avoid

• Never assume psychiatric etiology without excluding cardiac causes in high-risk groups (elderly, first presentation, abnormal vital signs, substance abuse) 1, 2, 3
• Do not dismiss tachycardia as "anxiety" without structured cardiac risk assessment, as this commonly delays diagnosis of true supraventricular tachycardia 7
• Avoid overlooking drug-drug interactions in polypharmacy, particularly CYP inhibitors combined with QT-prolonging agents 1
• Do not ignore persistent tachycardia in clozapine-treated patients, as this may necessitate dose reduction or adjunctive treatment rather than discontinuation 6