Episodic cardiac arrhythmia and accident rate

The rate of accidents severe enough to require a roentgen examination was investigated in a series of patients with episodic cardiac arrhythmia of types causing Adams-Stokes' syndrome. The accident rate was doubled compared with controls without known Adams-Stokes' syndrome but the associated increase in fracture rate was not significant.

'Cardiogenic vertigo'--true vertigo as the presenting manifestation of primary cardiac disease

BACKGROUND

A 90-year-old woman presented to a hospital emergency department with a brief loss of consciousness that was heralded by spinning vertigo lasting approximately 2 min. She had a long history of intermittent brief episodes of rotatory vertigo, presyncope, and non-vertiginous dizziness, occurring either with or without loss of consciousness. Although initially attributed to symptomatic carotid artery stenosis, these episodes persisted, despite surgical restoration of carotid artery blood flow 1 year after her first syncope. Her medical history was otherwise notable for hypertension, mild depression and a gradual decline in gait and balance function attributed to left hip arthritis and older age.

INVESTIGATIONS

Bedside history and examination, non-contrast head CT scan, electrocardiogram, transthoracic echocardiogram, and bedside cardiac telemetry.

DIAGNOSIS

Sick sinus syndrome or severe reflex bradycardia with asystole causing recurrent, episodic vertigo, presyncope, non-vertiginous dizziness and syncope (Stokes-Adams attacks).

MANAGEMENT

Placement of a temporary pacing wire, followed by surgical implantation of a single-chamber ventricular (VVI) pacemaker.

William Osler: slow pulse, stokes-adams disease, and sudden death in families

In 1903, William Osler, then at Johns Hopkins University, published "On the So-Called Stokes-Adams Disease (Slow Pulse with Syncopal Attacks, etc.)" in The Lancet, classifying a syndrome in evolution. There are thinly disguised references to a brother and to himself in the article, suggesting that Osler was concerned about a family and personal predisposition. Osler's decision to move to Oxford was triggered in part by his personal concerns about cardiac disease. Then, in 1909, Osler contributed a chapter on Stokes-Adams disease to Allbutt and Rolleston's A System of Medicine, complemented by a brilliant pathologic section by the renowned anatomist-morphologist, Arthur Keith. Osler's original contributions involved his emphasis on the importance of family history, his careful clinical and natural history observations, and his recognition of the familial occurrence of bradycardia, Stokes-Adams disease, sudden death, and cardiomyopathy.

[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.

[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.

[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.

Recovery from congenital complete atrioventricular block

Congenital complete atrioventricular block without any other intracardiac anomaly reverted to sinus rhythm at the age of 7 years. The girl had had heart failure and Adams-Stokes attacks when aged 1 year, requiring pacemaker implantation. Electrocardiography confirmed sinus rhythm for the first time at the age of 7 years. At the same time, a treadmill test yielded a normal tracing without any arrhythmias.

[Evaluation of the state of cardiodynamics in patients with artificial pacemaker]

Cardiodynamic parameters were studied in 23 patients with an implanted cardiostimulator both at rest and in conditions of an isometric exercise test. Three types of blood circulation were identified, namely eu-, hypo-, and hyperkinetic. The individual types of circulation were shown to be correlated with the severity of the clinical course of the underlying disease. The isometric exercise test allowed the researchers to differentiate between adequate and inadequate responses of hemodynamics in patients with an artificial pacemaker. It is concluded advisable to investigate the hemodynamic state of patients with an implanted artificial pacemaker so as to decide on any corrective measures that may be needed.

The cardiac atrioventricular conduction system in familial amyloidosis with polyneuropathy. A clinico-pathologic study of six cases from Northern Sweden

Cardiac conduction disturbances are frequent in amyloidosis with cardiac involvement, but the pathogenesis of these electrocardiographic abnormalities is not clear. In the present study, the conduction systems in six patients with the Swedish variety of familial amyloidosis with polyneuropathy (FAP), have been analyzed. The results suggest that in FAP, direct amyloid infiltration of the atrioventricular conduction system accounts for the majority of the electrocardiographic disturbances.

Complete heart block and physical performance

Complete heart block (CCHB) is a very rare finding. The problems in such patients are: additional heart malformations, the appearance of Stokes-Adams or syncopal attacks, and the occurrence of different grades of ectopy. Most patients with CCHB without structural heart disease develop normally and can lead a normal life. If there are no Stokes-Adams attacks or high grades of ectopy at rest and exercise, they have a normal physical capacity and can perform strenuous work and sports. Increased stroke volume, cardiac enlargement, and extraction of very large amounts of oxygen from the blood were found to be compensatory mechanisms of adaptation. Some authors have discussed the possible role of training in this adaptation.

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.

[Sudden cardiac death due to conduction disorder. III. Is the so-called idiopathic AV block caused by a congenital abnormality?]

The aim of this third part is to discuss the nature and origin of the destructive lesion of the conduction system. A total of 53 hearts of patients dying from av-block was available for this study, and in morbid anatomy the commonest pattern of lesions responsible for av-block is destruction of the branching bundle and the origin of both bundle branches. The pathological processes found in the heart and conduction system are as follows: ischemic heart disease (49%), surgical lesions (15%), calcificatory destruction (6%), inflammatory destruction (6%), various distinct causes (11%), and primary av-block (13%). Main interest is focused on the group with primary heart block. Morphologically our series shows little fibrosis but an unexplained loss of conduction fibers and strikingly atrophic elements (filiform fibers). At attempt is made to explain the loss of conduction fibers as a consequence of the natural developing process which separates the atria from the ventricles, a separation essential for electrical stability of the heart. It is accepted that the accessory muscle bundles which characterize the Wolff-Parkinson-White syndrome are a failure in reduction of the muscle fibers running from the atria to the ventricles at an early embryological stage. If this same process runs to excess, the result must be an av-block. We consider a part of the so-called primary av-block to be a consequence of this process.

Adams-Stokes attacks associated with carotid sinus syncope. Pathogenesis and therapy of the carotid sinus syncopes

The pathophysiology and therapy of the carotid sinus syncope were studied by means of electrophysiological investigations and clinical observations in 84 patients suffering from carotid sinus syncope. The most important data and conclusions of the study are the following: 1. The most frequent cause of the carotid sinus syncope (Adams-Stokes) attack is the sinus arrest and a sinus block. 2 degrees-3 degrees av block can be observed less frequent in the course of syncope attack. 2. In a patient suffering from carotid sinus syncopes, disorders of impulse formation and impulse conduction of the heart are frequent. First of all, the association of the sick sinus syndrome and the carotid sinus syncope can be often detected. 3. It is not rare at all that the carotid sinus syncope occurs with extracranial obliterative disorders. Transitory cerebral ischaemic attack frequently develops on the stimulation of the carotid sinus area. 4. The drug -- atropine -- therapy of the carotid sinus syncope is usually insufficient. Generally, pacemaker implantation is the adequate treatment. Late results are very good after pacemaker implantation.

Clinical and histopathological profile of sarcoidosis of the heart and acute idiopathic myocarditis. Concepts through a study employing endomyocardial biopsy. II. Myocarditis

Through an approach employing endomyocardial biopsy, early diagnosis of acute idiopathic myocarditis is possible. The histopathological findings consisted of fragmentation of muscle bundles, degenerative changes with lysis of myocytes and interstitial mononuclear cell infiltration. The cells were irregular in size and shape and contained slightly basophilic cytoplasm or were mixed with small round cells. Early clinical symptoms consisted of flu-like symptoms, i. e., higher fever, myalgia, malaise and arthralgia. Initial ECG changes consisted of complete A-V block in 9, bifascicular block in 3, and intraventricular conduction disturbance in 4 cases. Serial biopsies were performed at the early (0--2 weeks), middle (2--4 weeks), and late stages (more than 4 weeks) in 6 cases. Two of these biopsies were performed in 6 cases and all 3 were performed in one case. The numerous interstitial cell infiltration had almost disappeared by the early stage. At the late stage, either a slight or moderate degree of interstitial fibrosis was observed. These observations coincided well with the improvement of the ECG findings. Characteristic laboratory findings consisted of high LDH, GOT, and serum amylase levels. Varieties of treatments such as temporary cardiac pacing, peritoneal or hemo-dialysis, vasodilator therapy effectively to relieve the grave clinical condition. It is concluded that acute myocarditis may heal with remarkable improvement when the appropriate treatment is applied at the early stage of the disease.

[Treatment of tachy-arrhythmias by implanted pacemaker (author's transl)]

A recently developed antitachycardic pacemaker was implanted into seven patients with drug-resistant tachycardias. The implantation was made after diagnosis of a tachy-arrhythmia by invasive techniques and after experimental determination of the effective site, optimal mode and effective frequency of stimulation, as well as the regulation and duration of impulse release. Thus the pacemakers were individually adapted to the particular arrhythmia. High-frequency stimulation and competitive stimulation were used as stimulation modes. The systems work automatically, triggered either by the ECG, the patient or externally. The frequency of attacks was significantly reduced in five patients, the duration of attacks in all.

[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.

Effect of ventricular extrasystoles on idioventricular rhythm in patients with complete heart block

Idioventricular rate, QRS width, site of block and responses to premature ventricular stimulation were studied in 23 patients with chronic complete heart block in an attempt to distinguish patients liable to syncopal attacks. Seven patients were asymptomatic, five gave a history of presyncope and 11 of syncope. Although the mean idioventricular rate of the nine patients in the narrow QRS group (39.7 per min) was significantly faster than that of the 14 patients in the wide QRS group (35.3 per min; P less than 0.05), the rate did not distinguish symptomatic patients within either the narrow or the wide QRS groups. His bundle studies of the site of block and the effect of single and paired right ventricular stimulation upon idioventricular rhythm were also unhelpful. The response of the return cycle to increasingly premature ventricular extrasystoles, however, proved more complex than was anticipated.

Ventricular overdrive suppression of idioventricular rhythm in patients with complete heart block

Idioventricular rate, QRS width, site of block and responses to ventricular overdrive pacing were studied in 29 patients with chronic complete heart block in an attempt to distinguish patients liable to syncopal attacks. Ten patients were asymptomatic, 5 gave a history of presyncope and 14 of syncope. Although the mean idioventricular rate of the 10 patients in the narrow QRS group (40.0 per min) was significantly faster than that of the 19 patients in the wide QRS group (35.5 per min; P less than 0.02), the rate did not distinguish symptomatic patients in either the narrow or the wide QRS groups. His bundle studies of the site of block were also unhelpful. Overdrive right ventricular pacing at increasing rates was used to assess ventricular escape times which were not significantly different in symptomatic and asymptomatic wide QRS patients. There was, however, a significant difference in the product of maximum ventricular escape time X overdrive cycle length between symptomatic and asymptomatic narrow QRS patients after 30 s overdrive (3.850+/-1.670 vs 1.070+/-0.475; P less than 0.01); 60 s overdrive (5.020+/-2.170 vs 1.240+/-0.515; P less than 0.01) and 120 s overdrive (6.040+/-2.900 vs 1.460+/-0.275; P less than 0.01) which may have clinical predictive values.

Unusually high pacemaker threshold in severe myxedema. Decrease with thyroid hormone therapy

In a patient with myxedema and complete heart block, an usually high pacemaker threshold was observed initially during transvenous right ventricular endocardial pacing. The pacemaker threshold gradually decreased with thyroid replacement therapy, suggesting that the lack of thyroid hormone in some patients might increase the pacemaker threshold.

[Kearns' syndrome (author's transl)]

Kearns' syndrome, a rare cause of chronic progressive ophthalmoplegia was observed in three patients aged 15 to 54 years. Apart from the chronic progressive external ophthalmoplegia the syndrome consists of retinal changes and cardiac conduction defects in all cases, as well as other signs indicating damage to the nervous system. High tone deafness and vestibular damage as well as an increase in CSF protein are common. Endocrine disorders and skeletal anomalies may occur. The cause is unknown. The ophthalmoplegia may be of neurogenic origin. Adams-Stokes attacks following disturbances of cardiac rhythm may be prevented by timely implantation of a cardiac pacemaker.

[Adams-Stokes syndrome in a case of Mobitz type II AV-block triggered by premature atrial contractions]

The case of a patient with Mobitz type II AV-block is presented who suffered from recurrent dizzy spells and syncopal attacks. These episodes were due to intermittent asystoles lasting for 3-17 seconds, and it could be shown that they were triggered by two or more successive premature atrial contractions. The observation that there were no subsidiary escape beats or rhythms during the asystolic intervals and the ECG pattern for the conducted beats (RBBB and LAH) suggest an intraventricular (trifascicular) level of AV-block. The exact analysis of the asystolic pauses makes it likely that these were initiated by the penetration of the premature atrial impulses into the left posterior subdivision of the left bundle (concealed conduction). The present case demonstrates the fact that premature atrial contractions may produce prolonged asystolic attacks in patients with advanced intraventricular conduction disturbances.

A case of acute anterolateral infarction complicated with "left posterior hemiblock"

A case of transient left posterior hemiblock and various intraventricular conduction disturbances associated with acute anterolateral infarction is reported. The earliest manifestation was an appearance of ventricular premature systoles originated in the area of the left posterior fascicle. On following recordings left posterior hemiblock with periods of high grade A-V block developed. A few minutes later regular alternation of left posterior hemiblock and left anterior hemiblock was recorded in the presence of 2:1 A-V block. The mechanism for such rare manifestation is analysed. After representing complete left bundle branch block, spontaneous recovery of normal conduction was obtained without any change in heart rate.

Delay and block of cardiac impulse caused by enhanced phase-4 depolarization in the His-Purkinje system

The underlying mechanism of bradycardia-dependent bundle-branch and paroxysmal atrioventricular block appears to be enhancement of phase-4 depolarization in a branch or in a natural or acquired monofascicular pathway. Clinical records of these forms of impaired conduction occurring in the bundle-branches, with either longer or shorter cardiac cycle lengths, are presented and analysed. These also include the combination of Mobitz typw I atrioventricular block with variable degrees of bundle-branch block, as a representative example of narrow ventricular escape beats firing in the zone where prominent diastolic depolarization is present.

[Congenital complete atrio-ventricular block]

Case-histories and ECG of 23 patients with congenital atrio-ventricular heart block were studied. Most of these were up to 14 years old. In 10 of these patients concomitant congenital cardiac defects were uncovered which in 7 cases were combined with a corrected transposition of the major vessels. A relationship between the localization of the ventricular pacemaker and the clinical picture of the disease. The attacks of the Morgagni-Adams-Stocks disease were, as a rule, observed in patients with the ventricular pacemaker located beneath the bundle of His bifurcation, which manifested itself on the ECG by deformation and broadening of the QRS complex in the form of a complete or incomplete block of one or both of the bundle of His crura. Most patients with circulatory insufficiency suffered from severe concomitant congential cardiac failures or from frequent attacks of the Morgagni-Adams-Stocks disease.