British HeartJournal, 197I) 33, 35I-357. Br Heart J: first published as 10.1136/hrt.33.3.351 on 1 May 1971. Downloaded from Selected clinical features of paroxysmal A prospective study in I20 patients

Myron H. Luria' From the Division of Medicine, Saint Luke's Hospital, Cleveland, Ohio, U.S.A.

One hundred and twenty consecutive patients with paroxysmal tachycardia were personally evaluated in a prospective study. Some outstanding clinical features included the association of paroxysmal tachycardia and primary myocardial disease; the lack of palpitations in some patients with paroxysmal tachycardia; the relation of pectoris with paroxysmal tachy- cardia and ; the association of inferior and strictly posterior wall myo- cardial infarction with paroxysmal tachycardia; the unique presence of urina spastica in I9 2 per cent ofpatients; and the value of 'hunkering down' and sighing respiration in aborting attacks of rapid heart action. In addition, the role ofprecipitating factors in the onset of tachycardia and the finding that true paroxysmal ('PAT') appears to be an infrequent pheno- menon when the entire group of paroxysmal is considered, have been presented. The relative ineffectiveness of digitalis, quinidine, and pronestyl has also been evaluated in a selected group ofpatients with frequent episodes of rapid heart action.

Largely descriptive clinical studies have the criterion for the clinical diagnosis of paroxys- http://heart.bmj.com/ diminished in frequency. This may reflect the mal tachycardia and was substantiated by electro- many excellent descriptive studies of the past cardiogram in IOI patients. Careful attention was to I9 patients in whom a record of the as well as the with given present-day preoccupation tachycardia could not be obtained, particularly as methodology. In the past 30 years clinical to historical reliability. Each ofthese latter patients descriptions of the paroxysmal had repeated episodes of abrupt onset of tachy- have similarly been uncommon (Campbell cardia with symptoms of palpitations. and Elliott, 1939; Wolff, I942; Armbrust and Seventy-five patients were male and 45 female. Levine, I950; Nadas et al., I952; Jones, I954; The patients have been divided into 5 broad on October 2, 2021 by guest. Protected copyright. Lundberg, I963; Mackenzie and Pascual, groups aetiologically (Table i): idiopathic, short I964; Haynal and Matsch, i968), aside from PR syndromes, primary myocardial disease, itextbook reviews and occasional reports of rheumatic heart disease, and coronary heart unusual forms of treatment and rare electro- disease. Hyperthyroidism was not a feature in any patient. The age atonset ofparoxysmal tachycardia cardiographic rhythms. Unlike many of these is listed in Table 2. A preponderance of tachy- previous reports, the present study was under- cardia without a known cause reflects the clinically taken prospectively. Several distinctive clinical healthy population from which these patients features were found and evaluated which have were drawn. The benignity of paroxysmal tachy- hitherto received insufficient attention. cardia may be deduced from Table 3 wherein it is evident that recurrent rapid heart action may Patients persist for many years. with Of the IS patients with a short PR syndrome, From I965 to i969, I20 consecutive patients io had the Wolff-Parkinson-White syndrome paroxysmal tachycardia were personally evaluated (I930): one patient had an atrial reciprocating by the author. A history of sudden onset of rapid tachycardia, the probable mechanism for tachy- heart action unassociated with untoward acute cardia in most patients with a short PR syndrome cardiac disease such as an acute myocardial (Luria and Hale, 1970); 6 patients had supra- infarction or acute was used as without such a reciproca- Received 29 June 1970. ting mechanism clearly evident; 2 patients had 1 Address for correspondence: Dr. Myron H. Luria, paroxysmal atrial ; and one patient had St. Luke's Hospital, II31I Shaker Blvd., Cleveland, Ebstein's anomaly: however, an electrocardiogram Ohio 44Io4. could not be obtained during an episode of tachy- 352 Myron H. Luria Br Heart J: first published as 10.1136/hrt.33.3.351 on 1 May 1971. Downloaded from cardia in this latter patient. A short PR interval Coffee could be related to the onset of tachy- with a normal QRS configuration, the Lown- cardia in only one of the present I20 patients Ganong-Levine syndrome (I952), was seen in 5 and cigarettes in only two. patients during sinus rhythm. In 2 of these 5) Infection was associated with the onset of patients, paroxysmal supraventricular tachycardia tachycardia in ii patients who had no clinical occurred, and in one patient paroxysmal atrial involvement as fibrillation was found. An electrocardiogram evidence of cardiac such myo- could not be obtained during an episode of . In 6 patients this consisted of an tachycardia in 2 additional patients. upper respiratory infection; in 2 patients The diagnosis of primary myocardial disease pneumonia was present; and in 3 patients an was deduced by the clinical course and cardiac catheterization with left ventricular and coronary angiography in 4 patients who suffered from TABLE i Type and aetiology ofparoxysmal recurrent paroxysmal tachycardia as the chief tachycardia in 120 patients clinical manifestation of their cardiac disease. The incidence of rheumatic heart disease was low. On Paroxysmal Idiopathic Short Primary Rheu- Coron- Total the contrary, objective evidence of coronary PR myo- matic ary artery disease was present in I4 patients. This cardial heart heart perhaps reflects the changing pattern of cardiac disease disease disease disease in the United States. Ectopic atrial tachycardia 6 2 8 Supraventricular tachycardia 25 8 I 3 37 Clinical observations Atrial reciprocating tachycardia I I 7 I I 9 Precipitating factors The onset of tachy- Atrial fibriiation 25 3 2 2 3 35 cardia was often viewed mechanistically by AV 2 2 the patients as occurring in relation to some Ventricular tachycardia 5 2 7 Repetitive tachycardia: atrial I I specific event or movement. These may be ventricular I I divided into several general categories (Fig. I). Uncertain (no ECG) 13 3 3 I9 i) Sustained exercise complicated by par- Total 85 4 2 I20 oxysmal tachycardia was seen in 27 patients. I5 I4 Examples includemarching, dancing, running, swimming, and climbing stairs. 2) Sudden movement was noted just before the onset of tachycardia in 3I patients. TABLE 2 Age at onset and aetiology of http://heart.bmj.com/ Examples include bending over, turning paroxysmal tachycardia in 120 patients around quickly, standing up suddenly, and rapidly taking a deep breath. Age Idiopathic Short PR Primary Rheumatic Coronary Total myocardial heart heart 3) Psychic factors were notable in 25 patients disease disease disease and include the occurrence of anger, fright, or intense excitement; looking at television or 0-9 5 I 6 the movies; or reading a novel at the time of 10-I9 14 3 I7 20-29 2I 4 25 on October 2, 2021 by guest. Protected copyright. onset of the tachycardia. Dreams may have 30-39 12 2 2 3 I9 been of some importance in I0 patients who 40-49 18 3 2 I 3 27 were awakened from sleep with tachycardia. 50-59 9 I I 5 i6 In 2 of these patients a specific recurrent 6o-76 6 I 3 10 dream - falling off a cliff and a car accident, Total 85 15 4 2 14 120 respectively - appeared to be directly related to the onset of paroxysmal tachycardia. In order to further evaluate the role ofthe central nervous system, an electroencephalogram was TABLE 3 Duration of recurrent paroxysmal recorded in 7 patients. Minor non-specific tachycardia abnormalities during both paroxysmal tachy- cardia and sinus rhythm were observed in 2 Age at onset < I yr. yr. 6-Io yr. II-I5 yr. 16-30 yr. Total patients, the other records being entirely x-5 normal. Leptazol was infused in 2 patients 0-9 3 I 2 6 during sinus rhythm, but no electroencephalo- IO-i9 I 6 4 2 4 17 20-29 8 8 I 4 4 25 graphic or electrocardiographic alterations 30-39 7 6 2 4 I9 were elicited. 40-49 5 13 5 I 3 27 f 4) Chemicals such as poison gas (during a 50-59 3 9 3 I I6 practice military drill), parenteral epine- 60-76 5 3 2 I0 phrine, amyl nitrite, and alcohol were related Total 22 49 22 10 t7 I20 to the onset of tachycardia in 9 patients. Clinicalfeatures of paroxysmal tachycardia 353 Br Heart J: first published as 10.1136/hrt.33.3.351 on 1 May 1971. Downloaded from

ear infection, urinary tract infection with septicaemia, and recurrent prostatitis were present, respectively. Of considerable note 27 STAINED...... EXERdii was the association of an upper respira- ...... tory infection with all 8 episodes of supra- ventricular tachycardia in a 2-year-old girl 31 DDEN MOVEME whose paroxysmal tachycardia was first noted at the age of 2 months. A 53-year-old man also had 4 episodes of paroxysmal atrial 4Aa.-3 25 YCHIC FA fibrillation associated with upper respiratory I- Rl infections within 3 years, and a 77-year-old man had 4 episodes of paroxysmal atrial 0 9 flutter in 6 years, each associated with prosta- titis. z 6) Gastrointestinal upset was observed in 8 11 INFECTION patients before the onset of paroxysmal tachy- GIl cardia and was chiefly manifested by extreme t bloating or belching, especially after a large S meal.

Palpitations Palpitations are the sine qua o 10 20 30 non of tachycardia. However, their lack of full PERCENT

reliability was manifest in 8 patients with FI G. I Precipitating factors in 1 20 patients recurrent rapid heart action who had tachy- with paroxysmal tachycardia. GI, gastro- 4 arrhythmic episodes documented fortuitously intestinal. by electrocardiogram unassociated with an awareness of the tachycardia. In addition, 4 of these patients had never had palpitations: 2 angina pectoris during paroxysmal tachy- patients complained of chest pain (angina cardia, their age range of 40 to 66 years is pectoris) during their attacks, one noted consistent with the likelihood of coronary marked shortness of breath, and one became artery disease, which might be brought out http://heart.bmj.com/ very weak. In the majority, the palpitations only by a pronounced tachycardia. were readily noted and very bothersome, though patients with frequent attacks often Electrocardiograms Contrary to popular continued in their daily jobs if no other usage, so-called 'PAT', or paroxysmal atrial symptoms arose. Moreover, the rapid heart tachycardia, was an uncommon phenomenon action was often noted by acquaintances - and was observed in only 8 patients. The cigarettes in a shirt pocket moving in time to majority of patients with paroxysmal tachy- the heart beat, or, as noted by the wife of a cardia had either or supra- on October 2, 2021 by guest. Protected copyright. patient, movement of the bed in time to the ventricular tachycardia of undetermined rate of the heart. origin. The latter connotes a tachycardia wherein the ventricular rate is regular but in Angina pectoris Chest pain frequently which P waves are not discernible. The site of accompanied the tachycardia and usually con- origin of these supraventricular tachycardias sisted of a vague praecordial aching sensation. may thus be either in the atria or AV junction. However, 17 of the I20 patients had pain The differentiation of ectopic atrial tachy- typical of angina pectoris during their attacks cardia and atrial flutter was an additional and indeed 5 patients obtained relief with difficult clinical problem and was often judged -rutroglycerin during the tachycardia. One of by the atrial rate. One woman had paroxysmal these I7 patients, a 2i-year-old man who was ectopic atrial tachycardia with 2: I AV con- otherwise in good health, had paroxysmal duction with an atrial rate of 214 beats a ventricular tachycardia. Ten other patients minute. The 9 patients with atrial flutter also had objective clinical and electrocardiographic generally had 2:I AV conduction before evidence of coronary artery disease. Three of treatment with digitalis was begun, but by the 4 patients who died in this study are in- definition their atrial rates were above 250 'cluded in this group. Each died at home very beats a minute. suddenly without a clinical picture of rapid Of the rarer arrhythmias, both the atrial heart action at the time of death. Though and ventricular varieties of repetitive tachy- overt manifestations ofheart diseases were not cardia (Gallavardin and Dumas, 1924; present in the remaining 6 patients with Parkinson and Papp, I947) were seen in 2 354 Myron H. Luria Br Heart J: first published as 10.1136/hrt.33.3.351 on 1 May 1971. Downloaded from patients. Three patients had ventricular day-to-day work and shopping. Many ex- extrasystolic beats with occasional runs of pressed the feeling that 'there seems no end to paroxysmal ventricular tachycardia in the it' and if they could only 'get it all out, it absence of demonstrable heart disease. Four would stop.' Another described it as 'like patients had recurrent paroxysmal ventricular taking a water pill.' One 57-year-old house- tachycardia which was more sustained and wife developed angina pectoris with each epi- which frequently could only be stopped with sode of tachycardia and found it difficult to either intravenous procainamide or cardio- scurry back and forth to the bathroom. Her version. unique solution was to lie in bed on a bed pan for 60 to 70 minutes after the onset of Twelve patients rapid heart action while passing large amounts had objective evidence of an old myocardial of urine. infarction electrocardiographically and are of special note. Two of the 3 patients with Halting the tachycardia The majority of anterior wall infarction had paroxysmal patients with paroxysmal atrial, junctional, or ventricular tachycardia whereas all 9 patients supraventricular tachycardia of undetermined with inferior wall infarction had recurrent origin soon found that their rapid heart action supraventricular arrhythmias. Furthermore, 4 was limited in length and lay down or rested of these latter 9 patients also had involvement in a chair until it subsided. It was the rare of the strictly posterior wall. patient in whom physical manoeuvres of vagal stimulation invariably aborted the attack, Urina spastica A remarkable renal re- though often when one previously successful sponse to paroxysmal tachycardia is polyuria, manoeuvre was not effective another was. In termed 'urina spastica' by Wenckebach and the present series, though carotid sinus pres- Winterberg (1927). Twenty-three of the I20 sure at times was effective in 17 patients, the patients had urina spastica associated with Valsalva manoeuvre in 8 patients, gagging in their rapid heart action, an incidence of 19 2 6 patients, and eyeball pressure in 5 patients, per cent. No relation to a specific arrhythmia each patient, nevertheless, could not be was evident (Table 4). Though urina spastica entirely confident of abbreviating all episodes. At these times, medical advice was often sought. This usually consisted of pharma- http://heart.bmj.com/ TABLE 4 Prevalence ofpolyuria in paroxys- cological means of vagal stimulation via blood mal tachycardia pressure rises such as phenylephrine in 2 patients or metaraminol in 2 patients. The Paroxysmal arrhythmia Patients With effectiveness of the most commonly used polyuria medication, intravenous cedilanid (9 patients), may also be related to the Ectopic atrial tachycardia 8 2 production of a Supraventricular tachycardia 37 II transient rise in blood pressure (Ross, Atrial reciprocating I Waldhausen, and Braunwald, I960) and tachycardia on October 2, 2021 by guest. Protected copyright. Atrial flutter 9 resulting vagal stimulation. Atrial fibrillation 35 4 The above AV junctional tachycardia 2 physical methods of vagal Ventricular tachycardia 7 I stimulation were usually learned from a Repetitive tachycardia: atrial I physician. Of particular note were the experi- ventricular I ments ofpatients on their own. Seven patients Uncertain (no ECG) I9 5 found that by leaning over with the head down, Total 120 23 especially in a squatting position, but also from a sitting position, the attack of supra- ventricular tachycardia could be aborted (Fig. 2). Three of these patients felt that this might might appear before the onset of tachycardia be too conspicuous when at work and had or after an episode had terminated, it usually individually modified the position so that they began within I0 or iS minutes after the onset appeared to be tying their shoes. It is notable of rapid heart action. Large amounts of urine that the term squatting was usually not used were then passed at frequent intervals for one to describe this manoeuvre by patients from to one and a half hours and then gradually Appalachia, but instead a term from the declined, both in frequency and amount. Up eastern Kentucky patois, 'hunkering down', to I500 ml. urine have been passed in one was employed. According to Webster's hour by one of the present patients, and she Dictionary (I96I) 'hunker' is of Scandinavian has become well acquainted with the location origin and when combined with the word of all available rest rooms contiguous to her 'down' means to crouch or squat. The value (ulinical Of paroxysmal tachycaraia 355

features Br Heart J: first published as 10.1136/hrt.33.3.351 on 1 May 1971. Downloaded from

when the history of one of the present patients is examined. A 40-year-old housewife had 3 to 8 hour episodes of supraventricular tachycardia yearly. Following her third episode of rapid heart action, she was placed on maintenance digitalis therapy which was continued for one and a half years without the occurrence of rapid heart action. The drug was then stopped and for the past two years the patient has been asymptomatic. Was digitalis effective in this patient ? Ob- viously no reliable judgement can be made, but the vicissitudes of this paroxysmal disease are self evident. Twenty patients in the present series had episodes of rapid heart action of sufficient frequency - usually once per week but at least once monthly - so that the natural variation in the onset of tachy- cardia could be held to a miimum (Table 5). ffi. ::::.:. TABLE 5 Prophylaxis offrequent recurrent paroxysmal tachycardia F I G. 2 'Hunkering down' for paroxysmal Paroxysmal arrhythmia Patients Response* tachycardia. ,. (+) (-) Atrial fibrillation 8 digitalis 8 of 'hunkering down' may be related to the quinidine 02 g. q.i.d. 3 low position of the head with resultant quinidine 0o4 g. q.i.d. I 3 stimulation of the carotid sinus stretch receptors. Supraventricular tachycardia 12 http://heart.bmj.com/ digitalis 9 Another mechanism arrived at individually quinidine 02 g. q.i.d. 5 by 8 patients was sighing respiration or a deep quinidine 0o4 g. q.i.d. I breath. Scherf and Schott (I953) have termed procainamide 500 mg. q.i.d. 3 this a pulmonocardiac reflex and Bamberger (I857) had mentioned this measure in I857. * Response to prophylactic drug treatment: (+) Its mechanism is unknown. diminished frequency or elimination of symptoms of paroxysmal tachycardia; (-) no change. An alternative method of aborting an on October 2, 2021 by guest. Protected copyright. attack, electric countershock, was used in I0 patients not receiving digitalis. Five patients None had ventricular tachycardia or rheu- with supraventricular tachycardia of un- matic heart disease; one had pre-excitation; determined origin who were in clinical shock and 2 had evidence of inferior and strictly and had hypotension without palpable brachial posterior wall myocardial infarction. Each pulses were successfully treated. The method patient was given each medication for at was also particularly effective in 5 patients least 3 months, though some received with paroxysmal atrial fibrillation or flutter. pharmacological therapy for as long as 5 These latter specific paroxysmal arrhythmias years. In 8 patients with paroxysmal atrial previously often lasted 24 hours or longer fibrillation there was no change in the fre- despite various drug treatments. Electric quency of tachycardia with prophylactic countershock was applied expeditiously with digitalis; quinidine was ineffective in 3 intravenous diazepam anaesthesia. Within iS patients at o02 g. q.i.d. and in 3 other patients to 30 minutes the patients were fully awake at o04 q.i.d.; however, no episodes of tachy- and could be sent directly home when the cardia occurred for one year in one patient procedure was performed in the emergency when quinidine was increased to o04 g. q.i.d. room. In i2 patients with recurrent supraventricular tachycardia (of which 2 were discernibly Prophylaxis The difficulties inherent in ectopic atrial, one AV junctional, and 9 un- evaluating the prophylactic treatment of the determined in origin) there was no change in paroxysmal tachycardias are readily evident the frequency oftachycardia with prophylactic 356 Myron H. Luria Br Heart J: first published as 10.1136/hrt.33.3.351 on 1 May 1971. Downloaded from digitalis. Quinidine was ineffective in 5 of leptazol was injected. Further information these patients at 0-2 g. q.i.d. and in one might have been obtained if a diencephalic patient with pre-excitation it was ineffective lead system had been employed, but this is at 04 g. q.i.d.; procainamide in a dose of presently impractical. 500 mg. every 6 hours was also ineffective in An intricate relation between coronary 3 of these patients. Though digitalis did not artery disease and recurrent episodes of diminish the frequency of tachycardia in any paroxysmal tachycardia existed in patients patient, one patient with paroxysmal atrial with angina pectoris and myocardial infarction. fibrillation developed shorter episodes with Since a pronounced tachycardia may con- the drug. Moreover, in 5 patients with spicuously increase oxygen consumption of paroxysmal supraventricular tachycardia, digi- the heart, periods of rapid heart action may talis administration was accompanied by less have represented a natural form of an exercise intense subjective palpitations, greater effect- tolerance test, especially when symptoms iveness of physical means of aborting the typical of angina pectoris were produced in tachycardia, as well as shorteningofthe periods the present patients. Though Wolff (I945) of rapid heart action. Not included in this has emphasized that an absence of angina group of i8 patients are 2 patients, one with pectoris in paroxysmal tachycardia does not atrial and another with ventricular repetitive preclude coronary artery disease, patients in tachycardia. The former did not respond to the present study without a high probability digitalis or quinidine and the latter did not of coronary artery disease did not develop respond to quinidine. On the contrary, in 2 angina pectoris at heart rates similar to those other patients, each with the centrally excit- with pain. The role of myocardial infarction able type of paroxysmal tachycardia, episodes appeared aetiologic. The high incidence of of rapid heart action were eliminated with inferior and also strictly posterior wall myo- propranolol 40 mg. q.i.d. cardial infarction may indicate significant disease of the nutrient vessels of the sinus Discussion node and its connecting conduction system, The pale, clammy, intensely anxious patient i.e. the right coronary artery. with rapid heart action makes an indelible Another relation was found between pri- picture not soon forgotten. The present study mary myocardial disease and paroxysmal was carried out prospectively in order to tachycardia. The customary clinical presenta- personally evaluate this clinical picture and tion of patients with primary myocardial http://heart.bmj.com/ several distinct clinical features have been disease is either one ofcongestive , considered. cardiac restriction, or left ventricular outflow Most patients diligently searched to relate tract obstruction (Goodwin et al., I96I). The the onset of their tachycardia to a specific present findings suggest that a fourth chief event. However, only 7 of the I20 patients presenting manifestation is recurrent paroxys- could consistently find some association for mal tachycardia. each of their episodes of tachycardia - the Urina spastica is a feature of paroxysmal 'tachycardie paroxystique ai centre excitable' of tachycardia which has gained considerable on October 2, 2021 by guest. Protected copyright. Gallavardin (I922). Though the listing of attention as a result of the writings of Wood precipitating factors is superficially impressive, (I963). The water diuresis has been attributed their variability and lack of specificity suggest to a mechanism involving left atrial distension that their relation to the onset of tachycardia and subsequent reflex antidiuretic hormone is questionable for the majority of patients, inhibition (Wood, I963; Luria, Adelson, and however significant they may appear in an Lochaya, I966a). Cardiac output is not raised individual episode of tachycardia. This has during the polyuria but creatinine clearance, previously been exemplified by medical total solute excretion, and free water clearance observations made in the Warsaw Ghetto are increased (Luria et al., I966a). The cause (Tushnet, I966), certainly at a time ofphysical of the large solute diuresis is unclear but a exhaustion, infectious disease, and immense selective increase in renal blood flow has been terror, wherein a lack of paroxysmal tachy- postulated. Previous surveys have also indi- cardia was noted. This low incidence of cated that urina spastica is not found in specificity has also led to a consideration of patients with . If these the similarities of paroxysmal tachycardia and latter patients are excluded, approximately epileptic seizure disorders (Nothnagel, I887; one-half of patients with paroxysmal tachy- Parrow, I966; Pasini et al., I967). The cardia are reported to have an associated present small series of standard electro- polyuria (Wood, I963; Luria et al., I966a). encephalograms is inconsistent with this latter The lower incidence in the present study may supposition, as are the two cases wherein reflect the effect of a prospective study. Clinicalfeatures ofparoxysmal tachycardia 357 Br Heart J: first published as 10.1136/hrt.33.3.351 on 1 May 1971. Downloaded from

Pharmacological therapy of the supra- The syndrome of short P-R interval, normal QRS ventricular paroxysmal tachycardias was complex and paroxysmal rapid heart action. Circulation, 5, 693. generally ineffective. Thus, though digitalis, Lundberg, A. (I963). Paroxysmal tachycardia in quinidine, or procainamide may appear infancy. Acta Paediatrica, Suppl. 143. effective in many patients with widely separ- Luria, M. H., Adelson, E. I., and Lochaya, S. (I966a). ated episodes of tachycardia, in a small group Paroxysmal tachycardia with polyuria. Annals of Internal Medicine, 65, 46I. of selected individuals with a predictable fre- Luria, M. H., Adelson, E. I., and Miller, A. J. (I966b). quency of paroxysmal tachycardia the results Acute and chronic effects of an adrenergic beta- were discouraging. Of note is that though receptor blocking agent (propranolol) in treatment digitalis did not diminish the frequency of of cardiac arrhythmias. Circulation, 34, 767. Luria, M. H., and Hale, C. G. (I970). The Wolff- tachycardia, symptomatic improvement was Parkinson-White syndrome in association with observed in some patients and the attacks atrial reciprocal rhythm and reciprocating tachy- were of shorter duration. The apparent in- cardia. British Heart Journal, 32, 134. effectiveness of quinidine may also be more Mackenzie, G., and Pascual, S. (I964). Paroxysmal subtle; higher doses might be more effective, ventricular tachycardia. British Heart Journal, 26, 44I. but gastrointestinal irritation then becomes a Nadas, A. S., Daeschner, C., Roth, A., and Blumenthal, prominent limiting factor. Propranolol was S. L. (I952). Paroxysmal tachycardia in infants and given to only a few of the present patients and children: study of 41 cases. Pediatrics, 9, I67. Nothnagel, H. (I887). Ueber Paroxysmelle Tachy- was thus not fully evaluated. However, its kardie. Wiener Medizinische Blatter, 10, I, 73. usefulness in these patients with the centrally Parkinson, J., and Papp, C. (I947). Repetitive par- excitable forms of paroxysmal tachycardias oxysmal tachycardia. British Heart Journal, 9, 241. has been previously shown (Luria, Adelson, Parrow, A. (I966). Use of anticonvulsive drugs in the and Miller, Gettes and treatment of recurrent cardiac arrhythmias. Acta I966b; Surawicz, Medica Scandinavica, I80, 4I3. i967). Pasini, U., Carvalho, E., Valada, L., Pileggi, F., Barbato, E., and Decourt, L. (I967). Incidencia de Alteracoes Electrencefalogrificas em Portadores de References Arritmias Cardiacas Paroxisticas. Arquivos Brasil- Armbrust, C. A., and Levine, S. A. (1950). Paroxysmal eiros de Cardiologia, 20, 71. ventricular tachycardia: a study of I07 cases. Ross, J., Waldhausen, J. A., and Braunwald, E. (I960). Circulation, I, 28. Studies on digitalis. I. Direct effects on peripheral Bamberger, H. (I857). Lehrbuch der Krankheiten des vascular resistance. Journal of Clinical Investigation,

Herzens, p. 363. Braumililer, Vienna. 39, 930. http://heart.bmj.com/ Campbell, M., and Elliott, G. A. (I939). Paroxysmal Scherf, D., and Schott, A. (I953). Extrasystoles and tachycardia; etiology and prognosis of xoo cases. Allied Arrhythmias, p. 247. Heinemann, London. British Heart Journal, I, I23. Tushnet, L. (I966). The Uses of Adversity, p. 63. Gallavardin, L. (I922). De la tachycardie paroxystique Thomas Yoseloff, New York. a centre excitable: enregistrement electrique du Webster, N. (I96I). Third New International Diction- d6but et de la fin de l'accas. Archives des Maladies ary, p. I103. Ed. by P. B. Gove. G. and C. du Coeur et des Vaisseaux, IS, I. Merriam, Springfield, Massachusetts. Gallavardin, L., and Dumas, A. (I924). Contribution a Wenckebach, K., and Winterberg, H. (1927). Die l'etude des tachycardies en salves. Archives des Unregelmassige Hertztaligkeit, p. 252. Wilhelm

Maladies du Coeur et des Vaisseaux, I7, 87. Engelmann, Leipzig. on October 2, 2021 by guest. Protected copyright. Gettes, L. S., and Surawicz, B. (I967). Long-term Wolff, L. (1942). Clinical aspects of paroxysmal rapid prevention of paroxysmal arrhythmias with pro- heart action. New Englandjournal of Medicine, 226, pranolol therapy. American Journal of the Medical 640. Sciences, 254, 257. Wolff, L. (I945). The cardinal manifestations of parox- Goodwin, J. F., Gordon, H., Hollman, A., and ysmal tachycardia. I. Anginal pains. New England Bishop, M. B. (I96I). Clinical aspects of cardio- J7ournal of Medicine, 232, 49I. myopathy. British Medical Journal, I, 69. Wolff, L., Parkinson, J., and White, P. D. (1930). Haynal, I., and Matsch, J. (I968). Paroxysmal Tachy- Bundlebranch block with short P-R interval in cardia. Akademiai Kiad6, Budapest. healthy young people prone to paroxysmal tachy- Jones, G. M. (1954). Paroxysmal auricular tachycardia: cardia. American Heart Journal, 5, 685. observations in 47 cases. Annals of Internal Medi- Wood, P. (I963). Polyuria in paroxysmal tachycardia cine, 40, 58I. and paroxysmal atrial flutter and fibrillation. Lown, B., Ganong, W. F., and Levine, S. A. (I952). British Heart Journal, 25, 273.