Br Heart J: first published as 10.1136/hrt.36.6.577 on 1 June 1974. Downloaded from

British Heart Journal, 1974, 36, 577-58I.

Angina pectoris with due to paroxysmal atrioventricular block: role of ischaemia Report of two cases

Paul Chiche, Robert Haiat, and Pierre Steff From Service de Cardiologie et Urgences Circulatoires, H6pital Tenon, Paris, France

Two patients who experienced pectoris resulting in syncope, caused by paroxysmal atrioventricular block, are reported. In both cases circulatory arrest occurred at the peak of the anginal attack. It was related in one case to ventricular standstill and in the other to runs of ventricular (wave bursts 'torsades de pointe'). In both cases abolition of the syncopal attacks was achieved by insertion of a permanent demand pacemaker. These observations illustrate one of the possible mechanisms of sudden death in patients with coronary disease. They stress the primary role of acute ischaemia in the genesis of both during an attack of angina and the course of asymptomatic atherosclerotic heart disease.

The occurrence of syncope caused by paroxysmal then lost consciousness for 45 seconds. The electro- atrioventricular (AV) block during attacks of angina cardiogram recorded during syncope (Fig. 2) showed pectoris in patients with ischaemic heart disease is complete AV block with prolonged ventricular standstill rare. To our knowledge only 5 documented reports (3 5 sec). A permanent demand pacemaker (Stanium http://heart.bmj.com/ We Monopolar) was implanted using the jugular vein. have been published so far. thought it relevant During a nine-month follow-up period the patient is to describe two new cases, which demonstrate one doing well: he is free of any syncope though he does of the possible mechanisms of sudden death in experience episodic anginal pain. patients with atherosclerotic heart disease. Summary A 78-year-old man with coronary insuffi- Case reports ciency and (right bundle-branch block Case I and left anterosuperior hemiblock) experienced, at the A 78-year-old man presented with a past history of peak of anginal pain, syncope caused by paroxysmal AV on October 2, 2021 by guest. Protected copyright. hypertension and mild renal insufficiency. In I969 he block and ventricular standstill. Relief from syncopal experienced for the first time an attack of angina pec- attacks was obtained after insertion of a permanent toris. Since I972 syncope frequently occurred at the demand pacemaker. peak of anginal pain, at rest or on exercise. The patient complained of typical constrictive pain, then fainted. Case 2 Syncope lasted less than one minute, and was associated An 8o-year-old woman presented with a past history of with urinary incontinence. Neurological emiation hypertension and mild cardiac failure. Since I97I she and two encephalograms revealed no abnormality. The repeatedly experienced short attacks of thoracic con- patient was referred to us in January I973 because of the strictive pain immediately followed by dizziness or recent recurrence of syncopal attacks. Physical exam- syncope. The patient was referred to us in May 1973 ination was non-contributory except for a grade 2/6 for cardiac evaluation. Physical examination was non- systolic murmur at the apex and a moderate cardio- contributory except for a grade if6 midsystolic murmur megaly on the chest x-ray film. The electrocardiogram at the apex. The basic electrocardiogram showed sinus showed sinus rhythm with right bundle-branch block rhythm with normal PR interval and left bundle-branch and left anterosuperior hemiblock (Fig. i). Paroxysmal block. The patient was placed under continuous electro- AV block was suspected and the patient was placed cardiographic monitoring. On several occasions the under continuous electrocardiographic monitoring. The tracing showed asymptomatic episodes of high degree next day at 5.45 a.m. he was awakened by a severe retro- AV block (Fig. 3). The day after referral the patient had sternal constrictive pain similar to the previous ones, thoracic constrictive pain identical with the previous Received 13 November 1973. ones and then lost consciousness. The electrocardiogram Br Heart J: first published as 10.1136/hrt.36.6.577 on 1 June 1974. Downloaded from

578 Chiche, Haiat, and Steff

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l11111 RLLF V1 2 3 V456 FIG. I Case 2. 9 January 1973. Sinus rhythm is present with normal PR interval and right bundle-branch block, with left anterosuperior hemiblock. http://heart.bmj.com/ FIG. 2 Case . 10 anuary 1973. 5 a.m. During a syncopal episode which occurred at the height of an anginal attach complete atrioventricular bloch with prolonged ventricular asystoleI7(.a5 sec) is recorded fromn the electrocardiogram.

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FIG. 3 Case 2. II May 1973. In the absence of anginal pain an asymptomatic high grade atrioventricular block with occasional capture is recorded. Br Heart J: first published as 10.1136/hrt.36.6.577 on 1 June 1974. Downloaded from

Angina pectoris with syncope due to paroxysmal atrioventricular block: role of ischaemia 579

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I-t-v FIG. 4 Case 2. 12 May 1973. During an attack of angina pectoris followed by syncope, wave bursts ('torsades de pointe') appear. recorded during the syncopal attack (Fig. 4) showed a The occurrence of a syncopal attack during an high grade AV block, and, for the first time, runs of episode of angina is rare (Gallavardin, I922; (wave bursts: 'torsades de Golden, I944). Pathogenesis of the syncope include pointe' (Dessertenne, I966)). The next day a permanent (Chiche, I972): increase in vagal tone; cerebral demand pacemaker (Stanium Monopolar) was implanted using the jugular vein. During a six-month follow-up ischaemia resulting from the reduction in myo- the patient is doing well: she is free of any syncope cardial performance due to acute ischaemia (Chiche, though does experience a few attacks of angina pectoris. I972); arrhythmias as especially observed in Prinz- metal's angina: (Dorra et al., Summary An 8o-year-old woman with coronary in- I968); ventricular (Raynaud et al., I969; sufficiency and left bundle-branch block experienced Schwartz, Schwedel, and Schwartz, I966), and syncopal attacks at the peak of anginal pain. Between the paroxysmal AV block which is discussed here. attacks of angina continuous electrocardiographic moni- Syncopal attacks caused by paroxysmal AV block toring showed episodes of high degree AV block which during angina, to our knowledge, so far have been remained asymptomatic. During an anginal attack syn- http://heart.bmj.com/ cope occurred and simultaneously wave bursts ('torsades mentioned in only 5 documented reports (Galla- de pointe') were recorded on the electrocardiogram. vardin, 1922; Botti, I966; Schwartz et al., I966; Relief from syncopal attacks was obtained after inser- Raynaud et al., I969; Faivre et al., 1972). Galla- tion of a permanent demand pacemaker. vardin (I922) was the first to report these in what is now a classical description: 'Every time the patients have violent attacks of angina they are subject to Discussion fits of dizziness or actual syncope. Slowing of the Asymptomatic atrioventricular (AV) conduction pulse cannot always be recorded because once the disturbances are known to occur in about 20 per attack ends everything returns to normal. Un- on October 2, 2021 by guest. Protected copyright. cent of cases in the acute phase of myocardial in- doubtedly it is only during an attack that one can farction. They are more frequent in posteroinferior notice the slowing or maybe the disappearance of (I5%) than anterior (5%) infarctions (Himbert the pulse ... The linking of the fits of dizziness or and Lenegre, I967). As a rule, they are due to rever- syncope to conduction disturbances is still more sible ischaemia of the AV node and are transient. likely to be true with the finding of an unusually Asymptomatic AV conduction disturbances are prolonged a-c interval in the venous pulse tracing'. probably caused by a similar mechanism, but are More recent cases (Botti, I966; Schwartz et al., quite unusual during an attack of angina. Auzepy I966; Raynaud et al., I969) have made it possible to et al. (I962) reported one case out of I95. A few state precisely the mechanism of the circulatory other reports (Prinzmetal et al., 1959; Bouvrain, arrest: ventricular pause (Case i), or 'wave bursts' Fortin, and Coumel, I963; Nadal-Ginard and ('torsades de pointe') (Case 2). This last term refers Cardenas, I973; Oliva, Potts, and Pluss, I973) in- to runs of ventricular tachycardia which have been clude cases seen during variant angina pectoris individualized according to their particular mor- described by Prinzmetal et al. (I959); in these cases, phology (Dessertenne, I966). When recorded on the degree of block varied from a second-degree three simultaneous leads the electrocardiogram block (Mobitz I (Nadal-Ginard and Cardenas, evidences remarkable periodical changes in QRS I973) or 2: I (Bouvrain et al., I963) to a complete amplitude (gradual decrease then increase) and (Nadal-Ginard and Cardenas, I973). orientation (the complexes seem to 'twist' them- Br Heart J: first published as 10.1136/hrt.36.6.577 on 1 June 1974. Downloaded from

58o Chiche, Haiat, and Steff

selves around the baseline). In American reports out angina (as anginal pain is a late and/or incon- '' are usually referred as 'tran- stant sign of myocardial ischaemia). As clearly sient ' (Schwartz, Orloff, and shown, ischaemia may lead to severe arrhythmias Fox, 1949) or 'chaotic ventricular tachycardia' and must be treated so in an endeavour to prevent (Scherf, Cohen, and Shafiiha, I967). sudden death (Chiche, I973). In our patients, syncope caused by paroxysmal AV block occurred at the peak of typical anginal References attacks which did not have the features of Prinz- attacks were to Amsterdam, E. A. (I973). Function of the hypoxic myocar- metal's angina. Anginal unlikely dium. Experimental and clinical aspects. American Journal have been caused by AV block itself, as they pre- of , 32, 46I. ceded the occurrence of syncope (Case i) or were Auzdpy, Ph., Lockhart, A., Himbert, J., Gerbaux, A., and not always followed by syncope (Case 2). They Lenegre, J. (i962). L'angine de poitrine spontanee. imply both a failure in the sinus conduc- Etude clinique et electrique de 195 observations de crises impulse breves. Bulletin et Memoires de la Socie'te Medicales des tion and a delay in the junctional escape resulting H8pitaux de Paris, 113, 209. in a ventricular pause, or allowing wave bursts to Botti, R. E. (I966). A variant form of angina pectoris with re- appear. The is likely to result from a current transient complete heart block. American Journal simultaneous decrease of the blood in the of Cardiology, 17, 443. supply Bouvrain, Y., Fortin, P., and Coumel, Ph. (I963). Modifica- atherosclerotic arteries of sinus and AV nodes tions inhabituelles de 1'ECG au cours de crises d'angines de (James, I969). In such cases the frequent onset of poitrine spontanees de d6cubitus: onde en d6me geante, atrial arrhythmias ( (Bouvrain bloc auriculo-ventriculaire fugace et modifications de et al., I963), sinus (Schwartz et al., l'auriculogramme. Archives des Maladies du Coeur et des Vaisseaux, 56, 96I. I966), or tachycardia (Botti, I966)) together with Chiche, P. (1972). Syncopes et insuffisance circulatoire cere- AV block may be explained on this basis. AV con- brale au cours de l'ischemie myocardique. I7 cas d'angine duction disturbances occurring during the anginal de poitrine syncopale. Nouvelle Presse Medicale, I, 2883. pain emphasize the preponderant role of myo- Chiche, P. (I973). Le traitement de l'infarctus du myocarde apres la phase aigue. Cahiers de Medecine, I4, 759. cardial ischaemia in their genesis. Gallavardin Chiche, P., Benaim, R., Chapelle, M., Drouin, B., and (I922) already stated, 'We can postulate that the Senikies, A. (1973). R6le de l'ischemie dans les alterations transient ischaemic disturbance which is the cause des fonctions ventriculaires gauches au cours de la phase of the attack of angina spreads to the His bundle.' initiale de l'infarctus du myocarde. Archives des Maladies

du Coeur et des Vaisseaux, 66, 457. http://heart.bmj.com/ In a recent report Nadal-Ginard and Cardenas Dessertenne, F. (I966). La tachycardie ventriculaire a deux (1973) referred to it as 'angina of the AV node or of foyers oppos6s variables. Archives des Maladies du Coeur the His bundle'. Ischaemia is known to result in et des Vaisseaux, 59, 263. severe arrhythmias as it may result in a transient Dorra, M., Waynberger, M., Nezry, R., and Slama, R. (1968). A propos d'une observation d'angor dit de Prinzmetal a decrease of left ventricular performance (Chiche forme syncopale. Etude coronarographique. Archives des et al., 1973; Amsterdam, 1973; Haiat et al., I973): Maladies du Coeur et des Vaisseaux, 6i, I043. in the very first hours of the acute phase of myo- Faivre, G., Cherrier, F., Cuilliere, M., Dodinot, B., and Hua, cardial infarction, arrhythmias occur at a time when G. (1973). Angor de Prinzmetal: apport de la coronaro- ischaemia is far more important than necrosis; in graphie. Archives des Maladies du Coeur et des Vaisseaux, on October 2, 2021 by guest. Protected copyright. 66, 579. many cases of sudden death (Lenegre, I958; Gallavardin, L. (I922). Angine de poitrine et syndrome de Killip, 1971) myocardial lesions are discrete or Stockes-Adams. Acces angineux a forme syncopale. Presse moderate. Medicale, 30, 755. The reason why syncopal attacks as a Golden, A. (I944). Syncope associated with exertional occurring dyspnea and angina pectoris. American HeartJournal, 28, result of paroxysmal AV block are relatively rare 689. during anginal episodes remains unclear. It is Haiat, R., Masquet, Ch., Denizeau, J. P., Piwnica, A., likely, however, that in many cases the conduction Gourgon, R., Chiche, P., and Bouvrain, Y. (I973). disturbances result in sudden death. L'ischemie aigue a la phase initiale de l'infarctus du myocarde. A propos d'un choc cardiogenique gueri par In our two cases, the syncope no longer occurred assistance circulatoire. Coeur et Medecine Interne, I2, 249. after insertion of a permanent demand pacemaker. Himbert, J., and Lenegre, J. (I967). L'Infarctus du Myocarde. The decision to use a pacemaker was even clearer Sandoz, Paris. as an underlying intraventricular conduction dis- James, T. N. (I969). The role of small vessel disease in myo- cardial infarction. Circulation, 39, Suppl. 4, 13. turbance (bifascicular block (Case i), left bundle- Killip, T. (197I). Arrhythmia, sudden death and coronary branch block (Case 2)) was present. It is assumed disease. American Journal of Cardiology, 28, 614. that prevention of sudden death was so realized. Lenegre, J. (1958). La mort subite dans l'atherosclerose cor- These two unusual case reports emphasize the onarienne. Revue du Practicien, 8, I847. Nadal-Ginard, B., and Cardenas, M. (1973). Prinzmetal's primary role of acute or subacute ischaemia in the angina with recurrent and transitory atrioventricular block. course of atherosclerotic heart disease with or with- Acta Cardiologica, 28, 214. Br Heart J: first published as 10.1136/hrt.36.6.577 on 1 June 1974. Downloaded from

Angina pectoris with syncope due to paroxysmal atrioventricular block: role of ischaemia 581

Oliva, P. B., Potts, D. E., and Pluss, R. G. (I973). Coronary Scherf, D., Cohen, J., and Shafiiha, H. (I967). Ectopic ven- arterial spasm in Prinzmetal angina. Documentation by tricular tachycardia, hypokalemia and convulsions in coronary arteriography. New England Journal of Medicine, alcoholics. Cardiologia, 50, I29. 288, 745. Schwartz, S. P., Orloff, J., and Fox, C. (I949). Transient ven- Prinzmetal, M., Kennamer, R., Merliss, R., Wada, T., and tricular fibrillation. American Heart3Journal, 37, 2I. Bor, N. (I959). Angina pectoris I. A variant form of Schwartz, L. S., Schwedel, J. B., and Schwartz, S. P. (I966). angina pectoris. Preliminary report. American J'ournal of Adams-Stockes syndrome during angina pectoris assoc- Medicine, 27, 375. iated with . American Journal of Raynaud, R., Brochier, M., Morand, Ph., Fauchier, J. P., Cardiology, 17, 426. Raynaud, Ph., and Chatelain, B. (I969). Une forme clinique de l'angine de poitrine: l'angor de Prinzmetal. Requests for reprints to Professor P. Chiche, Hopital Semaine des Hopitaux de Paris, 45, 2662. Tenon, 4 rue de la Chine, 75020 Paris, France. http://heart.bmj.com/ on October 2, 2021 by guest. Protected copyright.