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Bundle-Branch Block with Short P-R Interval in Healthy Young People Prone to Paroxysmal Tachycardia

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Bundle-Branch Block with Short P-R Interval in Healthy Young People Prone to Paroxysmal Tachycardia Bundle-Branch Block with Short P-R Interval in Healthy Young People Prone to Paroxysmal Tachycardia Louis Wolff, M.D., Boston Mass., John Parkinson, M.D., London Eng., and Paul. D. White, M.D., Boston, Mass. A.N.E. 2006;11(4):340–353 Aberrant ventricular complexes of the type gener- may be typically those of complete right or left ally recognized as indicating bundle-branch block bundle-branch block, or of intermediate or lesser were first produced by Eppinger and Rothberger,3,4 grades of aberration. Spontaneously, or following by the experimental division of the right branch of release of vagal tone by exercise or atropinization, the His bundle. Eppinger and Stoerk5 observed sim- there is a transition from aberrant ventricular com- ilar curves in five patients, and at autopsy demon- plexes to perfectly normal ones. Coincident with strated division of the right branch of the His bun- the change to normal ventricular complexes, the dle in two of these. The work of Cohn and Lewis,2 P-R interval increases from an unusually short one and of Carter1 indicated, however, that gross le- (never greater than 0.1 second) to one of normal sions of the main branches are not invariably found length, frequently almost doubling itself. In other at autopsy in patients who during life present this words release of vagal tone is accompanied by a type of electrocardiogram. lengthening of the P-R interval; this paradoxical va- Following these original contributions to the sub- gal effect is of considerable interest; its mechanism ject, bundle-branch block curves have been ob- is obscure. Another feature observed in these pa- served as a temporary sign during infections, con- tients is the occurrence of paroxysmal tachycardia, gestive failure, coronary thrombosis, tachycardias, or paroxysmal fibrillation or perhaps flutter. and various toxic states. In most if not in all of The phenomena just mentioned have been the reported cases the abnormal curves occurred present more or less consistently in all of our in patients with definite structural heart disease, or patients. The combination constitutes a type of with extreme tachycardia. The references already rhythm, or mechanism, which has not yet been cited1,2 indicate that the type of electrocardiogram described as such; it is probably not rare. Consid- under discussion may be obtained in the absence erable importance attaches to the recognition that of gross division of a bundle branch. bundle-branch block curves do not always indicate Experimentally, bundle-branch block curves organic heart disease. The case with which such may be obtained in normal hearts by causing an cases may be recognized will be apparent from the impulse to enter one bundle branch later than the description of our cases. other. The same result would be produced should the impulse travel through the bundle branches at CASE REPORTS different speeds or by an aberrant course. That such a mechanism may occur in human beings with nor- Case 1. S.O.S., married, male, aged 35 years when mal hearts seems likely from a study of the cases first seen by us April 2, 1928. described in the present paper, the presumption be- Occupation. Physical director. ing that vagal stimulation may, in certain individu- Chief complaint. Palpitation off and on for the past als, give rise to aberrant ventricular complexes. ten years. We have observed the occurrence of bundle- Present history. His general health has always branch block curves in healthy young adults and been excellent. Attacks of palpitation, which be- children with apparently normal hearts. The curves gan ten years ago, are brought on by excitement or This article originally appeared in The American Heart Journal in volume 5, issue 6, August 1930, pgs. 685–704. 340 r r r r r A.N.E. October 2006 Vol. 11, No. 4 Wolff, et al. Bundle-Branch Block with Short P-R Interval 341 exertion, and once followed the drinking of one or ameter was within normal limits. The supracardiac two glasses of whiskey. During the attacks, which shadow was small. The aorta seemed narrowed in come on about once a week and last about half an both antero-posterior and oblique views. The mea- hour, he is conscious of the heart beating rapidly surements were as follows: to the right of the mid- and irregularly, and occasionally during these at- sternum 5.9 cm., to the left 8.2, total transverse di- tacks he has listened to his own heart with a stetho- ameter 14.1, length 14.5, base 13.5, width of great scope, finding a grossly irregular rhythm. This has vessels 5.2, and internal diameter of thorax 30.5. been confirmed by his physician. During the parox- The blood Wassermann reaction was negative. ysm he feels somewhat weak but continues his ac- Later notes. (1) April 23, 1928. Is taking quinidine tivity. He does wrestling, boxing, swimming and sulphate in daily rations of grs. ix. There have been road work, running ten miles without any undue no more paroxysms of fibrillation. symptoms. A paroxysm of fibrillation once came (2) June 15, 1928. In perfect health. No more on while he was swimming and ended while the paroxysms. Is not taking quinidine. swimming was continued. Less frequent attacks of (3) August 24, 1928. Except for one or two very a different type of palpitation occur in which the short paroxysms of auricular fibrillation he has heart beats much faster and is regular except for been in excellent health. occasional intermittence. Blood seems to rush to (4) October 1929. He has been in excellent health, the head at such times. The attack is stopped by and has done strenuous athletic work. Several at- bending forward so that his head is low. Many ex- tacks of paroxysmal tachycardia have occurred, but aminations in the past fifteen years have failed to none of auricular fibrillation. Physical examination reveal any evidence of heart disease, though occa- negative. sionally the heart was said to be irregular. Electrocardiograms. Numerous electrocardio- Active service in the army lasted from May, 1917 grams were taken. When the patient was at rest to August, 1919. The patient is of a “nervous,” in- the usual finding was normal rhythm at a rate of trospective type. about seventy, with slight sinus arrhythmia, and Past history. Negative except for Neisserian infec- intraventricular block of the “right bundle-branch tion seventeen years ago, mild influenza in 1918, type.” The QRS complexes were greater than 0.1 and psoriasis one year ago. second in duration, with the T-waves directed Marital history. Married five years. Wife living opposite to the chief deflection. The P-waves were and well, but has never been pregnant. poorly marked, and the P-R interval measured 0.10 Physical examination. General condition excel- second (Fig. 1). Exercise (running up and down lent. Well developed and nourished, muscular, four flights of stairs) produced a sino-auricular healthy athlete in the pink of condition. The entire tachycardia rate 140–120, with perfectly normal examination was negative except that the tonsils ventricular complexes throughout (Fig. 2). The were large and the tip of the spleen was just pal- P-waves were now better marked, and the P-R pable. Heart. The cardiac impulse was felt in the interval definitely longer (0.16 second). After a fifth intercostal space 7.5 cm. to the left of the mid- rest of twenty minutes the bundle-branch block sternal line. The left border of dulness was 8 cm. complexes had returned. Following the injection and the midclavicular line was 9.5 cm. to the left of atropine sulphate (gr. 1/30 subcutaneously) the of the midsternal line. The heart rate was irregu- ventricular complexes again became normal, and lar, varying between 50 and 80 per minute, but the P-R interval measured 0.15 to 0.16 second there was a dominant rhythm. After exercise the (Fig. 3). heart accelerated moderately, but was normal in The last electrocardiogram, taken in October rate again in one to two minutes. The sounds were 1929, showed the normal type of complexes which of good quality; the first apical sound was redu- changed to right bundle-branch block when pres- plicated; there were no murmurs. The pulse form sure was exerted on the right vagus nerve. and artery walls were normal. There was no arcus (We are indebted to Dr. Hyman Morrison for the senilis. Blood pressure was 104 mm. mercury sys- privilege of studying this case.) tolic, and 70 diastolic. Roentgen ray report (“7 foot plate”). The heart Case II. D.C., single, male, aged 18 1/2 years shadow was rather round and wide acrosss the auri- when first seen by us March 20, 1928. cles, but was not “mitral shaped.” The transverse di- Occupation. College freshman. r r r r r 342 A.N.E. October 2006 Vol. 11, No. 4 Wolff, et al. Bundle-Branch Block with Short P-R Interval Figure 1. (Case I) Right bundle-branch block. The P-R Figure 2. (Case I) Immediately after exercise (running interval is 0.1 second. The rate is 72. Time intervals for up and down four flights of stairs). Sino-auricular tachy- this and succeeding figures = 0.2 second. Horizontal cardia, rate 140 to 120. The ventricular complexes are lines cut off intervals of 10−4 volt. normal, the P-waves are better marked, and the P-R in- terval is 0.16 second. Present history. His general health had always been excellent. Four years ago he had his first the left of the midsternal line. The left border of attack of rapid vigorous heart action with sudden dulness was 7.5 cm.
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