Atrial Flutter with Irregular Ventricular Response as a

Contraindication to DigitalisBy SEYMOuR B. LONDON-, AI.D., AND ROSE E. LONDON, M.D.

ALTHOUGH atrial flutter occurs at atrialrates of 230 to 350 per minute, or faster,

the ventricular response is usually at one halfthe atrial rate because of partial block ofatrioventricular conduction. This block is of)hysiologic origin, arising from the refrac-tory period of the atrioventricular node, andit may occur without obvious cardiac dis-ease.1-3 On the other hand, variations in theventricular response during atrial flutter4 in-dicate increased block, which may be associ-ated with disorders of the conduction system.Two cases are presented that illustrate the

potential danger of produeing complete atrio-ventricular block by the use of digitalis inatrial flutter with greater than 2 :1 block andemphasize the value of an external electriccardiac pacemaker in ventricular asystole thatmay follow such comuplete block.

Case ReportsCase 1

iA 47-vear-old womnan with no history of cardio-va1sceulalr disease or hypertension was found ona routine examination to be in good health exceptfor a grossly irregular rapid heart action. Thepulse rate varied between 120 and 130, and theblood pressure was 120/80. The heart tones wereof good quality, there were no iiiurniurs, and therewere no signs of enlargement or failure. An electro-cardiogram (fig. 1) demonstrated atrial flutterwith 2 :1 and 3 :1 ventricular response withWenekebach phenomenon. The atrial flutter ratewas approximately 300 and the ventricular rate130.

Although the patient felt well, it was thoughtwise to correct the arrhythmiia. She was hospital-ize(l and was given 1 lug. of digoxin in divideddoses. On the following day, an additional 0.5m1g. of (di-oxin was given. The atrial flutter per-sisted but now with fixed 4 :1 block (fig. 2A).Because of the continued flutter three doses of 0.2Gm. of quinidine were given three hours apart.By the evening of the second day variable blockhad recurred with resultant irregularity of the

From the Miami Heart Institute, Miami Beach,Florida.

920

pulse; an .additional 0.25 imig. of digoxill wasgiven. The next mliorning the electrocardiogramrevealed a flutter wave rate of 300 and an irregularventricular rate of approximately 60 (fig. '2B).Digoxin was discontinued because of the increasedatrioventricular block, but quinidine was continuedand the patient received five 0.2-Gmn. doses at3-hour intervals. At 8 :00 A.iAI. on the fourth day,with an electrocardiogram (fig. 2C) showing. nochange fromt the previous day, the patient wasgiven 0.25 log, of digoxin, making a total(doseof 2 ilg.. over 4 days. One hour later the p2atien1tsuddenly vomited and fell out of bed. She recoveredquickly but had four similar episodes during,the next 4 hoursF2.Each seizure, as described bythe nurses, consisted of nausea, flushing of theskini, and transient uineoinseiouiness, followed bypallor and perspiration. During the third seizure,an electiro(ardiogrmli.i (fig. 3) revealed persistentatrial flutter anid long periods of ventricular asy-stole. Ilmlmliediately ain external electric pa cemnakerwas applied and further seizures were tell lirinatedproiliptly by electric stimulation.A trial of isoprotereinol (Isuprel) sublingually,

7.5 img. at 10-miinute intervals was followed byteiliporary 2 :1 atrioveiltricular VespOflse an1ld fre-quent ventricular extrasystoles. Ten iiiiiutes afterlthe third dose of isoplroterenol, however, veii-tricular standstill (f 12 seconds occurred and wasassociated with an major conlvulsive seizure. There-fore the heart was driven intermliittentlv by thepacemaker for the next 12 hours until 4 :1 to6 :1 atrioventricular (conductiol returned with a

ventricular rate of 60 to 70. Thereafter the platieintregained her usual state of well-being, allld was

discharged without further medicrtioi. Electro-cardiograms showed persistent atrial flutter withvariable block until approximately 1 year later,when she was found to have a normal sinusmechanism with entirely normal tracing. (fig.4). She has re1niained well since.

Case 2A 74-year-old retired iron worker had suffere(l

a mnyocardial infarction 6 years previoluslv followedby eongestive failure, which was controlled bydigitalis and salt restriction. His electroeardio-granms (fig. 5) over the previous 2 years showedcomplete right bundle-branch block and a pro-

*Pacelllaker-MIoilitor, PAI-65, Electrodlyne Co., :Nor-wood, Massaclusetts.

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ATRIAL FLUTTER WITH VENTRICULAR RESPONSE

Figure 1Case 1. Lead II demsionwst)r(tinig atrial flutter with ieariable F-R relationship and IWenckie-bach phenomenon. AV represents the timie between the (itriail flutter impulse (A)and the e tricular actiation (1V). Alteriiate fflutter imkipuilses sho wingplhIhysiologicbloclk are not indicated as p)enietr(atinig the A V node. The initerrupted oblique lIinesfollowin9g flutter waie numiekibers 10 and 20 indicate a block of the impulse iu? the A4Vnode producing W~enc(/1;ebaeh phenioi en9oni.

longed P-R interval of 0.30 seeond. Over theperiod of 3 years, he developed repeated syncopalepisodes. He was hospitalized because of syncopalattacks and varying cardiac rhythms (fig. 6A and13). Because of increasing cop- estive heart failurehe was given 2.2.5 laig.. of ditgoxin over a 4-davperiod.

Despite several Stokes-Adams seizures of shortduration, he improved hy the fifth hospital day,being alert, talkative, and without complaints.On the morning of the final hospital day thepatient becanie extremely cyanotie and unrespon-sive, and sweated profusely. An electrocardiogramat this time showed atrial flutter with conipleteheart block. Over a period of ,an hour the patient'scondition deteriorated and complete ventricularasAystole occurred with persistent a trial flutter(fig. 7). Accordingily, the external electric pace-m11aker was applied, and the blood pressure andpulse rate were maintained artificially for 10 hours.No spontaneous ventricular activity appeared dur-ing this time, and gradually the clinical statusdeteriorated, despite the use of mnetaraminol andlevarterenol in large quantities. The urinary outputwas good but the respiratory rate gradually slowedand eventually stopped, and the ventricles failedto respond to further excitation of the pacemaker.

DiscussionThe determining factor in each case ap-

peared to be not the dosagre of digitalis usedbut rather the pre-existing abnormality ofconduction of the atrioventricular node. The

Figure 2A. Case 1. FiXed 4:1 bloch. following digitalizationSecond hospital day. (Lead (a'VF.) B. Case 1.Increase in bloc/i on third hospital day with furtherdligitalization. (Lead a V1.) C. Case 1. Tracingta/en 1 hour prior to onset of Stoles-Adansseizure on forith hospital (d1i0,. (Lead aVe,.)

addition of small doses of digitalis to anialready impaired atrioventricular node, re-

sulted in the production of partial to completeheart block with absence of nodal or ventricu-

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LONDON, LONDON

rigure 3Case 1. Sections of continuous electrocardiogram demonstrating prolonged ventricularasystole interrupted bg pacemaker (indicated by solid block) and short periods ofirregular ventricular activity followed by prolonged ventricular asystole. Fourthhospital day. (Lead aVF.)

riMure; %Case 1. One year later. Leads I, II, and III showingspontaneous conversion to normal sinus rhythm.

lar escape. In the second case, prior to theonset of atrial flutter, there was first-degreeheart block with a P-R interval of 0.30 sec-ond. In the first case, the depression of theatrioventricular node was manifest by theirregular ventricular response, which occurredin a pattern indicative of first- and second-degree atrioventricular block of the Weneke-bach type (fig. 1). This important considera-tion is well pointed out by Besoain-Santander,Pick, and Langendorf,4 who considered thepresence of an atrioventricular ratio greaterthan 2:1 to be evidence of a "disturbance ofatrioventricular conduction corresponding toP-R prolongation during sinus rhythm." Theclinical importance of this electrocardio-graphic sign is attested by our two cases inwhich proper appreciation of atrioventriculardepression might have prevented the seriousconsequences of drug therapy.

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ATRIAL FLUTTER WITH VENTRICULAR RESPONSE92

rN

oVL oVF

VI v3

rigure 6Top. Case A2. V, on the day of admission demonl-strating atrial flutter with irregular ventricularresponse. Bottom. V1, on followin~~gday showiinginorm,1~al insrhythin.

.~~~~%.

rigure 7

Case 2. Upper tracing shows,. atrial flutter with complete heart block and ventricular

asystole with ventricular response to percussion (indicated by black dots). Middle tracing

shows pacemaker driving the ventricle and atrial tachycardia. Lo-wer tracing shows

absence of spontaneous ventricular activity on discontinuation of pacemaker.

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OVR

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V4

rigure 5Case 2. Electrocardiogram demonstrating pro-longed AV conduction with, normal sinus rhythm.

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2LONDON, LONDON

In view of the possilility of producing atrio-ventricular block during the conversioi ofatrial flutter to sinus rhythm, it is well ad-vised that constant cardiac miioniitorinig, witha pacemaker-monitor be undertaken in alleases showing im)aired con(luetioll. Certain-ly in the first case, the use of an electric pace-maker' '; was lifesavinog iii maintaiminig veii-tricular activity until the drug effects hadsubsided.

SummaryDigitalis may have an ad(litivc effect oii

impaired atrioventricular conduction, so thatatrial flutter with variable ventricular re-spoiise miiay progress to comI)lete heart blockwith ventricular asystole.Two cases are presented of atrial flutter

with. variable ventricular response in whomventricular standstill occurred duringy digii-talis therapy.

External electric stimulation of the heart

can maintain the circulation in digiitalis-induced ventricular stan(lstill.

References1. KISsAINE, R. W., BROOKS, R., ANI) CLARK, T. E.:

Relation of supaarventrichir 1)aioxysmlal tahelyeardia to heart disease and the basal metabo-lism rate. Circulation 1: 950, 1950.

. PRINZMETAL, M., CORDAY, E., BUTLL, I. C.,SELLARS, A. L., OBLATH, R. W., AND FLEIG,WV. A.: Mechanism of the auricular arrhythmia.Circulation 1: 241, 1950.

:3. SHERF, 1)., \ND SHOTT, A.: Extrasystoles aIirlAllied Arrhythmia. London, Heineaiamu; NewYork, Grune ani1d Stratton, ITu. 19533.

4. BiESOAIN SA.NTANDI R, M., PicK, A., AND LANGEN-

DORF, R.: A-V conduction in auricular flutter.Circulation 2: 604, 1950.

5. ZOLL, P. M.: Resuscitation of the heart in ven-tricular standstill by external electric stimu-lation. New England J. Med. 247: 768, 1952.

(i. ZOLL, P. _M., LINENTIHAL, A. M., AND NoRmAN,L. R.: Treatmuent of Stokes-A(daos disease by.external electric stimtlulattion of the headt.Circulation 9: 482, 1954.

KV)

Do not rashly use every new product of which the peripatetic siren sings. Considerwhat surprising reactions may occur in the laboratory from the careless mixing ofunknown substances. Be as considerate of your patient and yourself as you are of thetest-tube.-SIR WILLIAM OSLIER. Aphorisms fromn His Bedside Teachings and WVritings.Edited by Williamn Bennett Bean, 2M.D. New York, Henry Schuiman, Inc., 1950, p. 103.

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SEYMOUR B. LONDON and ROSE E. LONDONDigitalis

Atrial Flutter with Irregular Ventricular Response as a Contraindication to

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1961 American Heart Association, Inc. All rights reserved.

75231is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TXCirculation

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