Unrecognized paroxysmal ventricular standstill masquerading as epilepsy: a Stokes-Adams attack

Recognition of cardiac syncope masquerading as epilepsy may be difficult in the Emergency Department. We report a middle-aged man with recent onset convulsions who posed a diagnostic puzzle before it was found that he had paroxysmal ventricular standstill with complete atrioventricular block: he made a complete recovery after temporary pacemaker insertion. The main lessons from this case were (1) a convulsive seizure of only seconds duration and with an abrupt return of consciousness suggests syncope not epilepsy, (2) repeated, convulsive syncopes without provocation suggest cardiac syncope, (3) a 12-lead ECG should be recorded as soon as possible after such a series of episodes and should not be discontinued until an event is captured, and (4) Emergency Department clinicians should be familiar with any automatic gain on their ECG machine, lest fast, atrial activity be mistaken for narrow complex tachycardia. In summary, a good clinical history is of prime importance in differentiating convulsive syncope from epilepsy, and a simple, non-invasive cardiovascular evaluation may help to diagnose the condition as cardiac syncope.

[Morgagni-Adams-Stokes after adenosine injection in a patient with WPW syndrome--a case report]

A case of a 16-year-old girl with left sided accessory pathway is presented. Following adenosine-induced termination of atrio-ventricular reentrant tachycardia the patient developed polymorphic ventricular tachycardia followed by preexcited atrial fibrillation with very rapid ventricular response and syncope. Arrhythmia was terminated by amiodarone infusion. Potential complications after adenosine injection are discussed.

[Variant angina pectoris associated with Morgagni-Adams-Stokes syndrome--case report]

We report a case of Prinzmetal angina initially manifested with short losses of consciousness in a 55-year-old man hospitalized in the Department of Coronary Artery Disease, Institute of Cardiology, Jagiellonian University Medical College in Cracow. Clinical symptomatology of the presented case, causes and mechanism of loss of consciousness in variant angina as well as treatment methods are discussed.

[Atrial standstill: a paralysis of cardiological relevance]

Atrial standstill is a rare arrhythmogenic condition characterized by the absence of electrical and mechanical activity in the atria, transient or persistent, and complete or partial. It can be "idiopathic", sporadic or familial, or secondary to Ebstein's anomaly, Emery-Dreifuss muscular dystrophy (X-linked), Kugelberg-Welander syndrome (autosomal recessive), and amyloidosis. Idiopathic familial atrial standstill is inherited as autosomal dominant trait with variable penetrance. To date, a few cases of familial forms of primary atrial standstill have been described. In each family, the number of affected members was small and limited to relatives of one generation. The genetic basis for familial atrial standstill is unknown. Recently a mutation in the cardiac sodium channel gene SCN5A associated with relatively rare genotypes for two connexin 40 polymorphisms has been reported. The diagnosis relies on the ECG demonstration of bradycardia, absence of P waves, and junctional narrow complex escape rhythm. Nearly 50% of patients suffer from Adams-Stokes attacks. In the primary persistent form, the atrial paralysis is paralleled by atrial dilation, mitral valve incompetence, and thrombotic complications, with high risk of thromboembolic complications. The treatment is addressed to the thromboembolic risk (anticoagulation), mitral incompetence (diuretics and vasodilators) and syncope (pacemaker implantation).

[Complete atrioventricular block (with Adams-Stokes syndrome) in systemic connective tissue disease. Electrocardiographic development in three patients]

The association of high grade atrioventricular heart block with systemic connective tissue diseases is very rare. To date, only sporadic case reports or reviews appeared in the literature. Three cases of such association observed by the author are described here. The patients were a 51 years old man with systemic sclerosis and two women, a 64 years old patient with visceral nodous seropositive rheumatoid arthritis, and second was a 74 years old patient with systemic lupus erythematosus, the oldest of the group of patients with this disease. In two of the three patients, Adams-Stokes attack was a cause of death. The author did not observe this high grade atrioventricular block in patients with systemic connective tissue diseases the last 32 years. First and second grade heart blocks were, however, o chi asionally seen and responded well to the treatment of the systemic disease. Thus, in patients with systemic connective tissue diseases and emergency symptoms, it is recommended to consider also this rare association. While, two decades ago, patients frequently died after the Adams-Stokes attack, the treatment of the high grade block is now successful due the permanent cardiostimulator. In the last years, there are almost no reports about the association of systemic connective tissue diseases with high grade heart block, presumably because of the efficient new treatment approached to systemic diseases including modern immunomodulation drugs.

[Prinzmetal angina pectoris associated with 3rd degree atrioventricular block]

The authors report on the case of a 61 year-old female patient who was repeatedly taken to hospital because of chest pain and temporary loss of consciousness. During her hospitalization there was no ST elevation on the ECG, sinus bradycardia, other times atrial fibrillation was detected. The diagnosis was made by Holter monitoring three years after the onset of complaints. At this time chest pain set in after midnight, which was followed by loss of consciousness. Significant ST elevation and IIIrd degree AV block were detected. The coronarography showed non-significant coronary stenosis. According to the vasospastic patomechanism nitrate, calcium antagonist and acetylsalicylic acid therapy was administered and because of the complete AV block leading to syncope a VVI, M pacemaker was implanted. During the two years passed since the implantation of the pacemaker the patient had chest pain only once and it was not accompanied by syncope.

[Malfunction of a permanent pacemaker]

Forty years have gone by since the first pacemaker implant; this fact had strong impact in the life of thousands of persons. The objective of this work is to report the case of definitive pacemaker malfunction with epicardiac lead and review the literature concerning the important aspects of the causes and diagnosis of pacemaker malfunction. We consider that physicians dealing with patients implanted these devices must be prepared to diagnose and treat them adequately.

Borrelia burgdorferi as a cause of Morgagni-Adams-Stokes syndrome. Long time follow-up study

According the literature atrio-ventricular blockade (AVB) is the most frequent and well-known symptom of Lyme carditis. Typical signs of complete AVB include fatigue, lethargy and syncope- Morgagni-Adams-Stokes syndrome (MAS). The authors present their results and experience with 5 patients selected from a long-term study (conducted between 1987 and 1998) comprising 58 patients who developed MAS. The authors tried to evaluate the changes especially in the cardiovascular system. They correlated the clinical state with ECG findings, as well as with the levels of the Borrelia burgdorferi antibodies. The following results were obtained: 1) all patients had typical syncope, 2) the clinical course was not complicated (except one patient who developed ventricular fibrillation), 3) two patients had frequent symptomatic and asymptomatic arrhythmia including chest pain and episodic rest dyspnea, 4) subjective difficulties (usually palpitations) correlated with ECG findings (Lown 3a, 3b). The authors also looked for any relationship between clinical difficulties and levels of antibodies. The results obtained with an early permanent pacemaker were less favourable than those reported in the literature. Despite early treatment 2 patients had repeated palpitations and ECG correlates during the next years.

Acute nonspecific carditis in adolescents presenting with Stokes-Adams attacks

Three patients, aged between 12 and 17 years presented with Stokes-Adams attacks as a result of atrioventricular block, atrioventricular silence and ventricular arrhythmias, complicating acute myocarditis. All the patients required temporary pacing for a few days. One patient required hemodialysis for anuria. All the patients made complete recovery.

[The use of an implantable ECG recorder in the diagnosis of puzzling sporadic syncopes]

A 70-year-old man had passed out three times in six years, and was suspected of having a rhythm or conduction disturbance. Repeated hospitalization with telemetric monitoring had not revealed any disease. An implantable ECG recorder finally revealed the occurrence of symptomatic sinus arrest (Adams-Stokes attack), a month after discharge from the hospital. The patient was treated with a pacemaker. The cause of recurrent syncope can be difficult to diagnose. There is always a danger of overdiagnosis or under-treatment. Prospective study and cost effectiveness analysis are needed to determine the proper place of the implantable ECG recorder in the diagnosis of this disease.

[The runaway pacemaker syndrome during electrical ventricular stimulation of the heart]

The paper reports a case of escaping pacemaker syndrome in a female with continuous endocardial ventricular pacing. The syndrome was provoked by defects in the electronic scheme because of weakening of pacemaker's battery.

[Equipment and possibilities of dynamic monitoring of arrhythmia during permanent electrocardiostimulation]

The APKA cardiocomplex was developed, which diagnoses short intermittent arrhythmias in patients with and without cardiocomplexes. The cardiocomplex may operate in inpatient conditions of the cardiosurgical and cardiological units which are engaged in cardiac rhythms and in outpatient conditions of the outpatient monitoring and functional diagnosis rooms.

Management of Stokes-Adams syndrome

Stokes-Adams attacks are related to paroxysmal or chronic atrioventricular (AV) block (50-60%), sinoatrial (SA) block (30-40%) or paroxysmal tachycardia or fibrillation (0-5%). In between attacks most patients present with sinus rhythm, a large part with widened QRS complex. A minor proportion of patients present with chronic AV block. ECG is very rarely normal. Diagnosis is based on ECG recording during fainting. In patients with sinus rhythm and bundle-branch block or AV block, ECG monitoring should be performed in hospital, since Stokes-Adams syndrome in these patients is a potentially life-threatening disease. In sick sinus syndrome where the suspected arrhythmia is not life-threatening, ambulatory ECG by Holter monitoring can be performed to establish the diagnosis. In cases where ECG monitoring leaves doubt, an electrophysiologic study including His bundle electrography and sinus node recovery time may support the diagnosis, although normal findings do not preclude the diagnosis. Pacemaker implantation should be performed in Stokes-Adams syndrome, as oral drug treatment is ineffective. The dual-chamber pacemaker presents the advantages of both physiological heart rate and AV synchrony, but has troublesome side effects. Most patients with tachycardia/bradycardia syndromes require supplementary anti-arrhythmic treatment, and in some patients additional long-term anticoagulation should be considered.

Q-T interval in congenital complete heart block

The rate-corrected Q-T interval (Q-Tc) was measured in 273 children with congenital complete heart block. Fifty-nine had prolonged Q-Tc and 50 of these had symptoms. All 10 with isolated complete heart block, prolonged Q-Tc and bundle branch block had symptoms. The ventricular rate (VR) was significantly lower in patients with prolonged Q-Tc than in their age-matched controls. The outcome is worse for children with low VR and long Q-Tc than for those with low VR and normal Q-Tc. In 11 children a prolonged Q-Tc preceded symptoms by more than 1 month. This suggests that prolonged Q-Tc in children with congenital complete heart block can be of prognostic significance.

Predictive use of routine 24-hour electrocardiography in suspected Adams-Stokes syndrome. Comparison with cardiac rhythm during symptoms

Using strictly defined criteria of significant arrhythmias, long term electrocardiographic recording has been evaluated for confirmation of arrhythmias as the cause of cerebral symptoms in 81 patients with suspected Adams-Stokes syndrome. Extension of long term electrocardiographic recording for more than 24 hours gives marginal additional information at a high cost. Among 43 patients monitored until symptoms appeared, non cardiogenic causes were confirmed in 20 of 22 patients because the recording showed normal rhythm during symptoms. Fifteen of 21 patients with a significant arrhythmia during an asymptomatic 24 hour recording later had the same arrhythmia during symptoms. Of 38 patients who failed to develop symptoms, 21 had a significant arrhythmia detectable within 24 hours and 23 when 48 hours of recording were analysed.

[Syncope. An important border-line between neurology and internal medicine (author's transl)]

It is important for the neurologist to know the variations of the Adams-Stokes's attack so that the important differential diagnosis between an epileptic reaction and an Adams-Stokes's attack due to cardiac rhythmic disorder can be made. The Adams-Stokes's syndrome is not only due to asystoles in the sense of cardiac arrest but also to ventricular fibrillation and especially to the very common syndrome of the pathological sinoauricular node. The great importance of digitalis overdose is pointed out as an eliciting factor for the kind of arrhythmia which runs a course similar to that of the Adams-Stokes's syndrome.

Long-term ECG in ambulatory clinical practice. Analysis and 2-year follow-up of 100 patients studied with a portable ECG tape recorder

A portable tape recorder for long-term ECG monitoring is described. Its light weight (500 g) and small size (138 X 115 X 39 mm) make its usage in routine clinical practice a practical proposition. The most important application has been in the differential diagnosis of Adams--Strokes syndrome. The results from the first 100 patients with a 2-yr follow-up are presented. The importance of GCG recording during the patients' relevant subjective symptoms is stressed. The mean duration of recording was 2.8 days. In the 28 patients with histories which fitted the symptoms of Adams--Stokes syndrome this diagnosis was confirmed by an arrhythmia recorded simultaneously with the symptoms. In 36 other patients with a similar history the diagnosis was excluded becase of a normal ECG during subjective symptoms. Of the 28 patients with Adams--Stokes sydrome, bradyarrhthmia was the causal factor in 20 patients and these had a pacemaker implanted, whereas the remaining 8 patients had a tachyarrhythmia, which wa treated with antiarrhythmic drugs. The 2-yrs follow-up revealed an improvement and a disappearance of the Adams--Stokes attack in all the patients with an implanted pacemaker. In several of the 36 patients in whom Adams--Stokes syndrome could not be confirmed the syncopal attacks disappeared spontaneously. A large number of arrhythmias, including ventricular and supraventricular tachycardia, 2nd degree AV block and sinus bradycardia were observed during symptom-free intervals in these 36 patients. The introduction of long-term ECG recording routinely in patients with dizziness and syncope of unknown reason has resulted in an increase of the number of patients with a confirmed diagnosis of the Adams--Stokes syndrome, and it has contributed to an increase in the incidence of pacemaker implantation in Malmö from 130 per million inhabitants in 1971 to 220 in 1973, and 1974, respectively.

[Pitfalls of the normal electrocardiogram]

The authors report the cases of 7 patients with a normal basal electrocardiogram, whereas they were all affected with a high risk cardiovascular condition: coronary insufficiency in 3 cases, paroxysmal arrhythmia in 4 cases. They recall the limits of the conventional ECG and emphasise interest of dynamic recordings, with effort tests, and/on continuous ECG recording in the identification of certain transient heart manifestations.

Recurrent electromechanical dissociation due to severe underlying coronary heart disease

Recurrent electromechanical dissociation, eventually fatal, presented as Stokes-Adams-like syncope in a patient with severe underlying coronary heart disease. Mechanical function was probably suppressed because of myocardial ischemia due to recent occlusion of the proximal right main coronary artery; the left main coronary artery had been occluded previously. Spasm of the proximal right coronary artery may have accounted for his recurrent attacks of pain and syncope. It is suggested that this clinical picture has a grave prognosis, demanding urgent therapeutic measures. While these measures are likely to be more hazardous than usual, the grave prognosis and potential for therapeutic success make them well worth the risk.

A-V block

In this report, 61 A-V block patients were analysed using HBE. According to the site of the block, these cases were classified into P(A)-H block, BH block H V block and mixed block. In P(A) H block group (23 cases), the permanent pacemaker implantation was not needed except for one patient with persistent heart failure due to marked bradycardia. Postmortem histology of this patient was well coincident to the results of HBE. In BH block group (18 cases), moderate number of patients were needed to have permanent pacemakers implanted (33%). RA pacing induced split H block with H-V prolongation and varied H and QRS configuration in two cases of this group. These phenomena may be well explained by the longitudinal dissociation theory. In H-V block patients, permanent pacemakers were implanted in all patients (12 cases). In this group, it is difficult to decide the exact location of block, either distal His, bifurcation or bundles, because of the difficulty to record the left or right bundle potentials in clinical practise. Finally, it is important to record the HBE in order to decide the exact site of block, and to choose the suitable therapy for A-V block patients.

Stokes-Adams attacks due to acute nonspecific myocarditis

Ten patients, all below 30 years of age (8 females and 2 males) developed Stokes-Adams attacks from complete heart block due to acute nonspecific myocarditis. Coexisting thyrotoxicosis was present in two patients and cardiogenic shock was seen in four. Temporary transvenous pacing was instituted in all but one patient. Except for two patients who developed permanent complete heart block, normal A-V conduction returned in between 1 to 12 hours after ventricular pacing in seven patients and after 12 hours of isoprenaline therapy in the final patient. The ECG returned to normal in six patients and all 10 patients survived their acute illness.