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PAROXYSMAL VENTRICULAR TACHYCARDIA OCCURRING in a NORMAL HEART by DAVID ROMNEY, M.B., B.Ch.(Dub.) Ex-Senior House Officer in Medicine, St

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PAROXYSMAL VENTRICULAR TACHYCARDIA OCCURRING in a NORMAL HEART by DAVID ROMNEY, M.B., B.Ch.(Dub.) Ex-Senior House Officer in Medicine, St Postgrad Med J: first published as 10.1136/pgmj.31.354.191 on 1 April 1955. Downloaded from I9I -J PAROXYSMAL VENTRICULAR TACHYCARDIA OCCURRING IN A NORMAL HEART By DAVID ROMNEY, M.B., B.Ch.(Dub.) Ex-Senior House Officer in Medicine, St. James's Hospital, Balham It is widely taught-and rightly so-that by sinus pressure will, of course, not affect the paroxysmal ventricular tachycardia is one of the rate in ventricular tachycardia. rarer arrhythmias, and is associated with grave In I953 Froment, Gallavardin and Cahen myocardial damage, with special reference to myo- offered a classification of various forms of cardial infarction. It is the least common, and paroxysmal ventricular tachycardia, and included most serious of the paroxysmal tachycardias, some case report. They described the following which contain four varieties of arrhythmia: supra- groups:- ventricular (auricular and nodal) 60 per cent.; (i) Terminal prefibrillatory ventricular tachy- auricular fibrillation, 30 per cent.; auricular flutter, cardia. 6 per cent.; and ventricular tachycardia, 4 per (ii) Curable and mild monomorphic extra- cent. systoles, with paroxysms of tachycardia. Figures from various sources (Campbell, 1947) (iii) Paroxysmal ventricular tachycardia due toby copyright. would indicate that in the latter group, four-fifths a lesion of the ventricular septum. of the cases had seriously damaged hearts. In (iv) Persistent and prolonged ventricular tachy- the remaining fifth no cause was found for the cardia developing in sound hearts, usually paroxysms. Paroxysmal ventricular tachycardia is in young subjects. more common in men than in women in the proportion of about 3.2. This arrhythmia was Case Report first identified by Sir Thomas Lewis in I909 and A married woman, aged 48, first became aware Gallavardin (1920, I921, 1922) emphasized the in 1948 of a paroxysm which caused alarm, faint- seriousness of the 'terminal ven- ness and It lasted a short pre-fibrillatory collapse. only time, http://pmj.bmj.com/ tricular tachycardia,' and also described a less and past history was completely negative fromthe common type characterized by short attacks with point of view of cardiac symptoms, rheumatic frequent extrasystoles. Also at this time work phenomena, etc. At this stage she was seen at was published by various authors which stressed the National Heart Hospital, and clinical, radio- myocardial infarction as the precipitating cause logical and electrocardiographic examination was of the attacks, and pointed out the therapeutic normal. Later she became aware of a ' fluttering action of quinidine in these. Froment (1932) in the throat' from time to time, which gradually. classified paroxysmal ventricular tachycardia and seemed to pass off after a few hours, and give on September 30, 2021 by guest. Protected included a subgroup of paroxysms occurring in rise to no real discomfort once she became used normal hearts, and since then several large series to it. of cases have been reported, among which were In October I953 the paroxysms became more Campbell (1947) and Armbrust and Levine (1950). prolonged and she sought medical advice. She Aids to the diagnosis of paroxysmal ventricular was seen in St. James's Hospital, Balham. At tachycardia by the bedside are said to be varied that time her E.C.G. was normal, and no abnor- intensity of the first heart sound and slight mality was found on clinical examination except irregularity on careful auscultation; although these occasional extrasystoles. She continued to complain may be present, their appreciation by the human of attacks, and quinidine was employed, but this ear at rates of 200 per minute is another matter. merely added nausea and sweating to the discom- Campbell considers that the rate per minute does fort of the paroxysms which were then lasting up not help in distinguishing ventricular and auricular to days at a time. tachycardias, and that the faster rates were found In November I953 the first E.C.G. of the in the more healthy hearts because these alone arrhythmia was obtained which illustrated numer- could survive at these rates. Vagal stimulation ous extrasystoles occurring at a rate of about 200 G1 Postgrad Med J: first published as 10.1136/pgmj.31.354.191 on 1 April 1955. Downloaded from 192 POSTGRADUATE MEDICAL JOURNAL April 1955 .7r. 1-T -t ......q . -.- Tr . .m 3:Es . 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L L L X 1= 1 s I *1 Telr w | [r I r |x w x- I K I- U K 1= w X I w 1 -EX S i ] X fi | |L s X S zr tEH^I1I -11 ls-Lii LLI I is * lU X Li r l I| rl-rra ii I f | r.ifnRTtttT+ltH *-Tl .............................. r1 x r 1 i -11 nlii E- x x r w=z - | ..- E , ii |., ii s i s s sil .{1 ] | x w''Showingr'I--T' trsTr-1wTTparoxysms.- ................ § r E.of [T- s.-monomorphic s- X- r s. ventricular extrasystoles interspersed with normal sinus beats (8.I2.1953). per minute, interspersed with normal sinus heats permanent extrasystolic irregularity, interspersed every 10-I5 seconds. Sinus pressure was ineffec- with paroxysms of tachycardia of brief duration. tive. The patient experienced a vague fluttering In more severe forms these become longer, until sensation in the neck, but never angina or they coalesce into prolonged attacks' which are dyspnoea. interrupted by sinus beats only at infrequent Quinidine was discontinued, and she was given intervals. It is found in young subjects with pronestyl (procaine amide), 250 mg. t.d.s. This healthy hearts, and is usually very resistant to appeared to revert her to normal rhythm, but therapy, including quinidine. The paroxysms are after 24 hours the same type of paroxysm recurred. strictly monomorphic, and the isolated extra-by copyright. An increase in the dose of pronestyl again appeared systoles have the same contours as those con- to revert her to normal rhythm, but when seen stituting the paroxysms. later in the out-patients' department it was evident Very rarely episodes of transient heart failure that pronestyl in doses of up to 3 g. daily was can occur when the episodes are severe and pro- having no effect on the arrhythmia. longed, and occasionally faintness or vertigo may The patient thinks she can initiate a paroxysm occur at the beginning of an attack. In two by stretching her arms above her head, or making cases described by Froment, Gallavardin and a sudden movement. The commencement of a Cahen the ectopic rhythm disappeared, and after paroxysm causes no discomfort, but if it lasts for many years there were no abnormal findings onhttp://pmj.bmj.com/ 24 hours or more causes her to feel faint and examination.' The authors suggest that the lesion uncomfortable. When in normal rhythm no may be a microscopic myocardial injury, probably abnormality was noted apart from an occasional of the bundle of His acting as an ' epine irri- extrasystole. There is no evidence of coronary tative.' ischaemia; chest X-ray was normal; full blood count was normal; B.M.R. was minus o.5; and This type differs from Type IV which is W.R. and Kahn were negative. characterized by prolonged ventricular paroxysms A trial withdrawal of pronestyl in February without a break-analogous clinically to supra- on September 30, 2021 by guest. Protected I954 seemed to increase the severity and duration ventricular paroxysmal tachycardia. Clinically, of the paroxysms, so that the patient took to bed the beginning and end of the paroxysms are for a few days, and the drug has now been resumed abrupt; these often last some days, and are well in doses of 3 g. daily. When last seen in March tolerated. They do not conform to Type II as I954 no abnormality was found, and although she there are neither isolated extrasystoles nor any is having paroxysms lasting hours every other day, short periods of normal beats. is able to carry on her work as a shop assistant. Post-paroxysmal E.C.G. changes are often seen Froment, Gallavardin and Cahen quote two in Type IV involving inversion of the T waves, case reports of this type, who were resistant to but these are apparently of no prognostic sig- treatment, and who were followed from the ages nificance. Quinidine was successful in terminat- of 33-64 (female) and 17-41 (male) when the ing these paroxysms in contrast to those of paroxysms gradually ceased. Type II which were resistant to treatment. In the case report of Type III the paroxysms Discussion ceased after successful W.R.
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