paroxysmal ventricular tachycardia: astudy one - .auricular tachycardia, auricularfibrillation,...
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Paroxysmal Ventricular Tachycardia: A Study ofOne Hundred and Seven Cases
By CHARLEs A. ARMBRUST, JR., M.D., AND SAMUEL A. LEVINE, M.D.
A review is presented of 107 cases of paroxysmal ventricular tachycardia. In the majority it wasassociated with acute coronary thrombosis or coronary sclerosis, in some with rheumatic valvulardisease, and in others with no organic heart disease. It is generally critical and demands carefulattention. Occasional cases are overlooked because only one heart sound is present for each cardiaccycle and the heart rate is misjudged to be one-half the actual rate. The outlook often is serious ifthe condition is not effectively treated. Therapy generally is successful in controlling the arrhyth-mia. The most valuable drug is quinidine. Other medications are magnesium sulfate, atropine,potassium salts, and possibly morphine.
P AROXYSMAL ventricular tachycardiais one of the less common types of par-oxysmal rapid heart action. In spite of
its rarity, prompt diagnosis and treatment aremost important because often the patient's lifeis at stake and with proper therapy the resultsmay be excellent. The arrhythmia occurs pre-dominantly in patients with serious organicheart disease and this, in addition to the effectof the rapid ventricular rate, makes it impera-tive that the attack be terminated as soon aspossible if a fatal outcome is to be averted.
Lewis1 reported the first case of ventriculartachycardia. His patient was a seaman who hadrepeated premature ventricular contractions oc-curring singly and in runs of as many as 11beats. Shortly after Lewis' publication in 1909,reports2-4 of isolated instances of this arrhyth-mia appeared which were followed by reportsof larger series and more complete reviews. -8Lewis9 produced ventricular tachycardia indogs by ligating the coronary arteries andRobinson and Herrmann"O called attention tothe relationship of paroxysmal ventriculartachycardia to coronary occlusion in man.Scott,1" in 1921, was successful in controllingthis arrhythmia by the use of quinidine admin-istered orally. There was 1:1 retrograde con-duction to the auricles and no evidence oforganic heart disease. The present study of 107cases is reported with the hope of clarifyingsome of the problems of diagnosis, prognosis,and treatment encountered in patients with thisdisorder.
From the Medical Clinic of the Peter Bent Brig-ham Hospital and the Department of Medicine,Harvard Medical School, Boston, M1ass.
All cases of paroxysmal ventricular tachycardiaoccurring in the Peter Bent Brigham Hospital andthe private practice of one of us (S. A. L.) from 1915to 1948, inclusive, have been studied. Sixteen of
0-9 10-49 20-29 30-39 40-49 50-59 60-69 70-79 80-8s 90-99AGE IN DECADES
FIG. 1.-Age Distribution of Cases
TABLE 1.-Types of Underlying Heart Disease1. Coronary Artery Disease ..................... 792. Rheumatic Heart Disease .................... 93.NoH eart D isease 134. Miscellaneous Group
(A) Wolff-Parkinson-White Syndrome ........ 5(B) Congenital Heart Disease ................ 1
these cases have been reported previously."2-16 Thetotal number of episodes of ventricular tachycardiaobserved in this study of 107 subjects was 131.The youngest patient was 13 years of age and theoldest 83 years. The age distribution by decadesis shown in figure 1. The average age was 54.8years. Seventy-one patients were males and 36 werefemales. The types of underlying heart diseaseare shown in table 1, and it will be noted that
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CHARLES A. ARMBRUST, JR. AND SAMUEL A. LEVINE
coronary artery disease was present in 74 percent of the patients. The duration of the attacksvaried from a few seconds to twenty-three days.Eighty-two patients had persistent attacks (hoursto days) and 25 had intermittent attacks (secondsto a few minutes). The ventricular rate during theepisodes varied from 138 to 292 with one exception;in one patient the rate was 115.
The bedside findings which suggest the clini-cal diagnosis of paroxysmal ventricular tachy-cardia have been described by Levine17',9and Strong and Levine.18 These consist of achanging intensity of the first heart sound at theapex, a slight irregularity of the ventricularcycle length, and the failure of vagal stimula-tion to produce any effect on the tachycardia.A changing intensity of the first sound was
noted in forty-three episodes. This sign will bedetected only on careful auscultation and isnot present in patients who have concomitantauricular fibrillation or in those in whom thereis 1:1 retrograde conduction. In the rare in-stance in which 2:1 retrograde conduction tothe auricles takes place one might expect tofind alternation in the intensity of the firstsound. The mechanism of production of thechanging first sound is thought to be dependenton the changing relationship between auricularand ventricular contraction, similar to thatwhich occurs in conjunction with completeheartblock.19 Excluding the patients with auric-ular fibrillation, a changing intensity of thefirst sound was noted in approximately 50 percent of the patients in this series.
In the common type of paroxysmal auricu-lar tachycardia the cycle length is perfectlyconstant, whereas in ventricular tachycardiaslight but detectable irregularities in the cyclelength may be observed in an appreciable num-ber of instances. The slight irregularities inrhythm in ventricular tachycardia can easilybe overlooked unless auscultation is carried outcarefully. Cooke and White7 on the other handfound thirteen of fifteen tracings of definite andprolonged paroxysms of ventricular tachycar-dia to be perfectly regular. Cooke and White7also found that irregular rhythm was mostlikely to occur during short paroxysms and inpatients with auricular fibrillation. Williams
and Ellis8 found only 4 of 24 patients with thepersistent type of tachycardia to have an ob-vious irregularity of the rhythm. In the 107episodes of the persistent type of tachycardiain this series, in 32 per cent the rhythm wasslightly irregular, while in 76 per cent of theintermittent type a similar type of slight ir-regularity was manifest. In considering theslight irregularity that is seen in paroxysmalventricular tachycardia it must be clear thatthe actual heart rate can be quite constantover long periods of time. It is the length ofcontiguous cycles that may change. The dif-ference may not be more than 0.03 secondthough occasionally it is much greater and maynot occur but once in many cycles. The ear isable to appreciate these slight variations incycle length. In contrast, the contiguous cyclesin the common type of paroxysmal auriculartachycardia rarely vary more than 0.01 secondin length.Paroxysmal ventricular tachycardia does not
respond to vagal stimulation. This finding ishelpful in the differentiation of ventricular fromparoxysmal auricular tachycardia, auricularflutter, and sinus tachycardia.
Gallarvardin20 described changes in the jug-ular pulse wave in patients with ventriculartachycardia. Further observations of the jugu-lar pulse during the arrhythmia have been re-ported by Prinzmetal and Kelley.2' In ventric-ular tachycardia the auricular rate is generallyslower than the ventricular rate and the pulsa-tions of the auricles at this slower rate may bevisible in the jugular vein. In addition, occa-sional prominent jugular waves will appear dur-ing cycles when the auricles are contractingwhile the ventricles are in systole. Such find-ings may be particularly helpful in those pa-tients in whom P waves are not visible in theelectrocardiogram. The abnormal jugular pul-sations will be absent in subjects in whom thereis no change in the intensity of the first heartsound, that is, in those with auricular fibrilla-tion and 1:1 retrograde conduction.There is one additional unusual auscultatory
phenomenon that merits discussion, particu-larly since it has not been hitherto described.There were three instances in this series inwhich only one heart sound could be heard
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PAROXYSMAL VENTRICULAR TACHYCARDIA
with each cycle. In 2 patients this resulted inthe heart rate being misinterpreted by someobservers as being one-half the actual rate. Inone of these patients, the sounds alternated inintensity so that they closely resembled thenormal sounds. It was difficult at the bedsideto tell whether the rate was 115awith two soundsto a beat or 230 with only one sound. This couldnot be determined from the radial pulse sincethe patient was pulseless and the blood pres-sure was not obtainable. The electrocardiogramquickly revealed the fact that the ventricleswere beating at a rate of 230. It is of interestthat in this case two physicians who had beenseeing the patient for some hours had over-looked the tachycardia and thought the heartrate was "about one hundred." Such expe-riences must be more frequent than has beenrealized as we have seen other instances ofparoxysmal rapid heart action in which onlyone heart sound could be heard with eachcardiac cycle.
In summary, one may state that there arebedside methods available which will enablethe physician to suspect the diagnosis of par-oxysmal ventricular tachycardia in most casesand even to make a fairly definite diagnosis inmany instances without the aid of the elec-trocardiograph.
The criteria for the electrocardiographic diag-nosis of ventricular tachycardia were first pro-posed by Robinson and Herrmann.11 They em-phasized three features. The first is the detectionof auric