paroxysmal atrial tachycardia with atrioventricular...

Paroxysmal Atrial Tachycardia withAtrioventricular Block

Its Frequent Association with Chronic Pulmonary Disease

By LEONARD M. GOLDBERG, M.D.. J. DAVID BRISTOW, M.D.,BRENT M. PARKER, M.D., AND LEONARD W. RITZMANN, M.D.

PAROXYSMAL atrial tachyeardia withatrioventricular block (PAT with block)

has been recognized more often in recent yearssince Lown and Levine clarified its diagnosticcriteria and emphasized its important relationto digitalis excess.1' 2 The present report wasprompted by the increasing frequency withwhich this diagnosis has been made at ourhospital and its common association withchronic pulmonary disease.

Methods and MaterialsThe electrocardiographic files at the Portland,

Oregon, Veterans Administration Hospital werereviewed for records demonstrating PAT withblock. The 5-year period from January 1954 toApril 1959 was covered. In those cases found,the clinical, laboratory, and autopsy data wereabstracted from the hospital charts. Emphasis wasplaced upon the type of heart disease present,details of digitalis and diuretic therapy, treatmentand course of the arrhythmia, and outcome of thebasic disease process. The electrocardiograms wereanalyzed for details of the arrhythmia, includingatrial and ventricular rates, configuration of theatrial complexes, types of A-V block, and asso-ciated rhythm disturbances.The diagnosis of PAT with block was made

solely on the basis of the electrocardiogram (fig.1). We utilized the criteria of Lown and Le-vine, 2 which include atrial rates of 150 to 250per minute; varying degrees of atrioventricularblock (usually 2:1, Wenekebach, or varying intype) ; P waves that are upright in leads II, III,and aVF, and altered in configuration from thosepreceding development of the arrhythmia; an iso-electric baseline between the P waves and a P-Pinterval that may be slightly irregular. The de-gree of A-V block may be increased by carotid

From the Veterans Administration Hospital aildthe University of Oregon Medical School, Portland,Ore.

massage or decreased by atropine or exercise. Ven-tricular premature contractions may be present.Sinee quinidine may slow the atrial rate of atrialflutter to below 250, we did not include cases inwhich quinidine had been given prior to develop-ment of the arrhythmiiia.

ResultsThe diagnosis of PAT with block was estab-

lished in 37 cases. The patients ranged in agefrom 33 to 89. Although only 1 patient wasfemale, this sex distribution is consistent withthe total population of our hospital. In gen-eral, the patients were seriously ill with ad-vanced heart disease. Thirty-four patients hadorganic heart disease with atherosclerotic, themost common type, present in over one thirdof the cases. Cor pulmonale was almost as fre-quent, occurring in 10 cases. In addition, therewere 4 cases of hypertensive cardiovasculardisease, 2 of rheumatic heart disease, and 1ease each of myocarditis, polyarteritis, con-genital heart disease, and dystrophic heartdisease (i.e., progressive muscular dystrophy).There were only 3 patients in whom no heartdisease could be demonstrated. Two of thesewere digitalized because of atrial tachyeardiaand subsequently developed PAT with block.The heart disease was accompanied by conges-tive heart failure in 33 cases.An unexpected finding was the high fre-

quency of serious pulmonary disease (table1); over one half of the patients had signifi-cant lung lesions. The most common was ad-vaneed obstructive emphysema, present in 10patients; other types included pneumonia,pulmonary embolism, bronehogenic carcinoma,and tubereulosis. A total of 22 lung lesioniswas found in 20 patients. That the pulmonary

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GOLABERG, BRISTOW, IPARKER, RITZMANN

Paro al atrial tachcardia witheYAV block

Figure 1Characteristics ofj PAT' with block-trod Il. The atrial rate is 16G. The A-V block is of-WenCkebach tqjup. lThe second, third, ind tootIrth QRS complexes (ti-C preceded by P-Roiter;vols of iceaOsiflygdurotion. -A P wiarte is boirn6ic nI the fourth Q9IS; its recntr'iculorresponse is blocked. The P) wcoves (ior notched. peaked, and seplatoted yi.'soelr tivic bane-lines. lItwonr)etiature ventricular contractions arte present.

litpoess ivas the pruimilatry disease in nmanyv in-

staines is attested to by tie fact that definiiteelectrocardiogr aplhie, clinical, or p)ostmortelnevideniee of cor plulmoiale was present in over

25 per cenit of the total series. Althougil Nw

nixe nio statistical data as to the frequeneyof pulmonary (lisease in- our digitalized pa-

tienits, it is ourt inpres;sioni that tle occurrenceeof PAT with block ini this gr'oup represenits a

ligher iincidence. thani would be expected bychanlce alone. siice the (listribuitioni of diagr-nostic categories ini our inistitutioni is approxi-

m'iiately thiat seenl ii most genieral medical and(Isurgrical Vet. ranis Adnmiiist ration Hospitals.

rrhe basic electroeardliorap)lic dliagnosis ofthe series encoml)l-assed a wide variety of ab-nlormiialities. Fourteeni eases had nonspecificSTrrr abnormalitiess colnsistent witlh myocar-

diall lisease or associated digitalis effect. Tlhesecond iimost freqtuenrt abnormality was riglhtvenltrieul in hvpc)ertroplhy- l)reseuit ini 7 cases.

con firmIingIq thle prev-iously mientioned highll inl-cidenl-ce of co.r l)llmloIiale. P'-pulmoiiale'(tall peaked 1' waves iii leads I1, III, anid

aV1Y) was also seeni to be frequent after theat rlhythlimia disappear ed. P-pulmolnale anid

right ventricular lhypertrophy did not alwayscoexist. The remainiing electrocardiogramsdeemnoistrated left bunidle-branch block, rigrhtbunidle-branch block, myocardial inifaretioni,

and left, veint ieular hIypertrnphy, all ini atp-pttoxiniately equal nium-Lbers.

rrhe IPAT witl blocvk was ehbaracterized mllostcoiniiionllv bx- at rial Irates betweceo 120 and(I 200per nininteC(table 2). rpTo 1atieijits hia(l atrialirates of 115 anIIi6 ra(liate s l)ettweelI 200 aind0240 (fig. 2). These (-eases wer'e othlerwise typi-ical of PAT w-ith block. In almtiost two thirdsof the groulp) the venttrinilar rate was lesstlhani 100, anid in onlly 1 iiist-anee was it above150 per minuimte. All types of ANV b)lock, fromBfirst degtree to eomlplete, were reeorded, anidin manyv cases there wvas a shift from onie typeto another. Tphe p)redoiniianit type of A-V1)loek was 2:1 (1.5 eases) cbhangin;g block and(iWeiuckebach phieno1menoit were preseint inlalmuost equlal niumbers. As al coniseq'_jueniee offlhe relativ-\7ely slowv ventricular rate and theoccasionally regnidar venitricular' rhlytlhmn (2:1block) ani arrhytltlhmia was fre(uenitly unsus-leeted atl the bedside. Indeed. it was often(liscovered iii. ani electroe ardiogra obtainedfor other j)utrposcs. 'When the rate was mi1orerapid anid the block changing, atrial fibrilla-tion was oceasionally siinulated.PAT with block was the sole rhytliini dis-

tutbance in onily 6 instances. Premiiature vemi-tricular conitrac-tions oftenl a sign of digitalisexcess, occurred eonieomitantly in IS eases. Avariety of otlher arrhythmias, lredolnitnantly

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PAROXYSMAL ATRIAL TACHYCARDIA

Table 1Types of Pulmonary Disease

Table 2Electrocardiographic Characteristics of Thirty-seven Cases of PAT with Block

Obstructive emphysemaPneumoniaPulmonary embolismBronchogenic carcinomaTuberculosisFibrothorax*PolyarteritisGranulomatosis

103 Rate per Less than More than

minute 100 100-120 121-150 151-200 200

2 Atrial 2 10 19 62 Ventricular 23 5 8 1

111

*Chronic tuberculous pleuritis with absent expani-

sion of the right hemithorax.

supraventricular, either preceded or followedthe PAT with block. Some of these, such asA-V dissociation and A-V nodal rhythm, alsowere thought to corroborate the suspicion ofdigitalis intoxication.At the time of development of PAT with

block all but 1 of the patients were receivingdigitalis. Although it was often difficult toestablish the presence of digitalis toxicity,especially in retrospect, review of the recordsrevealed that in 22 patients there were clinicalreasons in addition to the arrhythmia to sus-

pect digitalis toxicity. It was of interest thatall types of digitalis preparations were repre-

sented in the group. In 22 cases diuretics hadalso been administered shortly before thearrhythmia appeared. Nevertheless, the serum

potassium was reduced (less than 3.5 mEq.per liter) in only 4 of the 23 patients in whomit was measured prior to potassium therapy.PAT with block was managed by stopping

digitalis or by administering potassium saltsin 31 cases. Nine patients received procaineamide or quinidine in addition. Of this total of31, only 3 died with the arrhythmia persist-ing. In the remaining 6 patients the rhythmdisorder was not recognized and therefore nottreated, and 4 of this group died with it stillpresent. Despite the fact that only 7 patientsdied without conversion of the arrhythmia,18 were dead within 1 month after develop-ment of the PAT with block, and a total of22 died within 1 year. These figures point outthe seriousness of the underlying heart dis-ease with which PAT with block is usuallyassociated.

Type of A-V block

2:1VaryingWenckebachComplete

DiscussionThe principal arrhythmias with which PAT

with block may be confused are atrial flutter,atrial tachyeardia, and sinus tachyeardia. Theabsence of a constantly undulating baseline,the presence of upright P waves in leads II,III, and aVF, and an atrial rate less than 250are features that help to distinguish PAT withblock from atrial flutter. Occasionally theremay be confusion when the atrial rate in flut-ter is slowed by quinidine therapy. In thisinstance, however, the previous records andthe clinical history will be of diagnostic im-portance. Careful examination of the electro-cardiograms will reveal the evidences of A-Vblock that separate the disorder under dis-cussion from paroxysmal atrial tachyeardiaor sinus tachyeardia. A changed configurationof the P waves will also help to differentiatethis entity from sinus tachyeardia with A-Nblock.Although the atrial rate in PAT with block

is ordinarily said to be 150 to 250," 312 ofour cases had rates less than 150 per minute.In 2 of these the rate was 115 per minute,but all the other criteria for the diagnosiswere met. Indeed, Lown et al.3 in their recentseries of 23 cases listed 9 in which the atrialrates were less than 150, with one as low as100. Thus, we think that the usually statedrange should be broadened to encompassslower atrial rates.

Since the ventricular rates in our caseswere rarely greater than 120 and generallyless than 100 per minute, it seems unlikelythat the arrhythmia itself was directly detri-

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0( ( )I JDBERCJ BRISTOW, PARKER, RITZIMANN

M ALiT

Figure 2PAT withi block displayingy.rapid atlvio lo vndcent ricdul r tales in a patin t with cor pal-mnonale. PAT wiith lIVeclktebach type of A-V block developed ont 9 27/55 and wCas presentthe following dlty with a-t more rapid cenitricnlar roitc. Lslal bl)c;ci on s t-he 1P wtvte.Sinus rhythmn was restored 10 minutes after pirocaine amnde and Potassium therapy wvasbeygcun.

me1ntal. cardiae funeftion and bloodl flowv.Its ilplr)latalle, athller, Was thlat it delloted

p)otentially danger Ous dig-italis toxicity. Because .PAT with bloclk accoani(-omp ed serious

lhe.l t disase,s(s tlce prognosIsO for1the pacttients

inl. whom it wea1n1ws t lyv, though onotaIl arFs grave.

Thle( association o'f IPAT withl b)lo1ck andld (hi(i-taIlis toxicity las b eec clearly elucidated, as

has the frc'sponlse to potassium themap!- II

I rvesu1llits are con-firma1t-:ory iil both respects(fig 8). r1liTere wa(ls evidence of digitalis tox-

ieitv ill ailiimost two thirds of the patients, amid(

the arrlhythmuia ceased after withdraw al of

digitalis aiid adnIministratioi of potassiiii iiin28 of 31 patients. A low serumln potassillull w1asniot denioiistratecl in miost of our iatietits de-s)ite prior diuretie therapy. It is kniowni, howv-eeixo that in ncarl. all eliroinie diseases, ill-e lLcling conitgestive heart failure, the totalIo(dyv exchatgoeable potassium is low,'5 a statewell kinow a to potelltiate rlythm disorder-s byilereasing the effect of digitalis.)' 16

Althlough digitalis toxicity is usually int-crlllillated as a mnechaniism: in the genesis ofthis arrhythmyiia, a iiumuber of eases hiave beenreported in which dicitalis was Inot beinag]ven at the timXe thlis rhythym distubtrance


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PAROXYSMAL ATRIAL TA(JIY(ARDI) I 5

Figure 3Typicnal e,nphle of' )-f'nitlh blo 1: fr)omt a patient icitl e jrplonnftl. Tie first stripshows loner atriotl chqceardia qwith ax rate of 118. Twvo dlays inter, after rigorousdigitalis and liretie(hero'p PAT r-ifh Tlenlckebaeh phenomenon nospres,qent; sce-eeeded the following (10/f b/i perscs/en 2. V block. Potassium therapy restoreds'ootrh/th m ni/bin7i} honrs.

occur red)1' 17 At least 2 of our c.,ases.- fit this

category.Onle of, tlie most ilntere-stillg features of ouir

xxvas tfie assoeciatio of PAT withi blockand serious pulmonamv (lisease. -As stated pre-

viously, I-liee were 20 l)atietis in Axvliottw the

c,onditions eoexisted ain(l 10 in wh1om11 th1e nai-

jor c.ardiolo gic mliagiosis as cor- T)ilmnonlale.Ani association of PAT Awith block and(i chronielung, disease has not been described hereto-

fore. Althouglh som1ie authors havN-e ex)ressed

the opiniion tha--t arthytlnnias are inifreqpentin thie ipresciwe of ('or pulinonale 2' iS.1t

view is to thle contirary. Recent stu(lies tend

to conlfirniI this iIpressioni. Corazza and Pas-tort21 reporled that 31 per ctcit of 1222 pltieiltswitlh )ulmonary h- ear:t (lisease hiad1 airrhyvth-iiias. Tt is ktnowni that acidosis, anoxia,)ulmonary hyp-)ertension. and di.stentioon of'the righlt atrilum and(1 great veins, atny or all

Circulation, Volume XXY, April 1960

of wi cli wax exist ill th.e presenee of serioullspulmonary leart disease, mnay be associatedwith iniereasedi atrial irritabiblity and stitinla-tioni of ec(t)topic- pacemialkers. Tin addition pa-tielnts withi (oV publ onale tenid to respondpoorly to Illelieal measures, so that digitalisinay be g-iven iii larg,er thani usual ainoints inan .attemipt to impro- e rihlit heart failure.lianmn et al.2 hav+e reported f;liat of 29 patfientsw ith pulmoniarv insufflicienec, S exhibited evi-deuce-s of digitalis toxicity that thiev attrib-uited to anioxia. Whlatever thle cause, we thinkthat onie shouild le esp)ecially assi(duiouis iiwvatchingo for IPAT with block in dlgitalized1p)atiellts wvithl cot.. pulisn-lnnale.

SummaryP:aruoxysmn al at iial tachc ardtl waxx ithI block

is a eardiae arrlhythmi-ia tiat is uisually a man-ifestation- of dicitalis toxicity iu patients with

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G0&OLDBERG, BRISTOW, PARKER, RITZMANN

serious heart disease. The arrhythmia gener-ally ends promptly after potassium adminis-tration and withdrawal of digitalis. Since theventricular rates may be slow and regular,the arrhythmia may be difficult to recognizeclinically. Atrial rates as slow as 115 per miii-ute may be seen in cases which are otherwisetypical of the condition.

In our series associated pulmonary diseasewas present in 54 per cent and cor pulmonalein 27 per cent of the cases.

Summario in InterlinguaParoxysmic tachyeardia atrial con bloco es un

arrhythmia cardiac que usualmenite representa uimanifestation de toxicitate per digitalis in patientesconi serie miiorbo cardiac. Iste arrhythmia se terminlapromptemente in le majoritate del casos post le ad-ministration de kalium e le suppression de digitalis.Proque le frequentia ventricular pote esser lente eregular, il occurre que iste arrhythmia es difficile arecognocer cliniieamente. Frequentias atrial de nonplus que 115 per minuta ha essite observate in casosque es alteremente typic del conditioni.

In nostre serie, associate morbo pulmonar essevapresente in 54 pro cento e corde pulinonal in 27 procento del casos.

References1. LOWN, B., AND LEVINE, S. A.: Current Concepts

in Digitalis Therapy. Boston, Mass., Little,Brown & Co., 1954, p. 72.

2. , AiND -: Current concepts in digitalis therapy.New England J. Med. 250: 819, 1954.

3. -, MARCUS, F., AND LEVINE, H. D.: Digitalisand atrial tachyeardia with block. New Eng-land J. Med. 260: 301, 1959.

4. DEGRAFF., A. C.: Clinical Conference: Digitalisintoxication. Circulation 9: 115, 1954.

5. ENSELBERG, C. D., SImMONS, H. G., AND MINTZ,A. A.: The effects of potassium upon theheart, with special reference to the possibilityof treatment of toxic arrhythmias due to digi-talis. Am. Heart J. 39: 713, 1950.

6. FENICHEL, N. M.: Paroxvsmal atrial tachyeardiawith digitalis-induced atrioventricular blockunder observation for thirteen years. Am.Heart J. 44: 890, 1952.

7. LowN, B., SALZBERG, H., ENSELBERG, C. D., ANDWESTON, IR. E.: Interrelationship between po-tassium metabolism and digitalis toxicity in

heart failure. Proc. Soc. Exper. Biol. & Med.76: 797, 1951.

8. -, WYATT, N. F., CROCKER, A. T., GOODALE, W.T., AND LEVINE, S. A.: Interrelationship of dig-italis and potassium in auricular tachyeardiawith block. Am. Heart J. 45: 589, 1953.

9. PICK., A.: Clinical Progress: Digitalis and theelectrocardiogram. Circulation 15: 603, 1957.

10. FLETCHER, E., AND BRENr\MAN, G. F.: Par oxysnmalauricular tachyeardia with auricular-ventricu-lar block. Brit. M. J. 2: 79:2, 1957.

11. FREIERMUTH, L. J., AND JICK, S.: Paroxysmtialatrial tachyeardia with atrioventricular block.Am. J. Cardiol. 1: 584, 1958.

12. HARVEY, R. M., FERRER, M. I., AND COUR-NAND, A.:Treatment of chronie cor pulmiloinale. Cii-cula-tion 7: 932, 1953.

13. HEJMENCIK, M. R., HERRMAN-N, G. R., AND

WRIGHT, J. C.: Paroxysmal supraventriculartachyeardia complicating organic heart disease.Am. Heart J. 56: 671, 1958.

14. KRIESLER, J. E., AND KRIESLER, M. F.: Paroxys-mal atrial tachyeardia with A-V block: Reportof a case with unusual orthostatic effects. Am.Heart J. 54: 308, 1957.

15. BIRKENFELD, L. W., LEIBMAN, J., O 'MEARA, MI.P., AND EDEL-MAN, I. S.: Total exchangeablesodium, total exchangeable potassium, and totalbody ii-ater in edematous patients w ith cir-rhosis of the liver and congestive heart failure.J. Clin. Invest. 37: 687, 1958.

16. SIMONSON, E., AND BERMAN, R.: Differentiationbetween paroxysmal auricular tachyeardia withpartial A-V block and auricular flutter. Am.Heart J. 42: 387, 1951.

17. SPRITZ, N., FRIMPTER, G. L., BRAVEMAN, W. S.,AND RUBIN, A. L.: Persisteint atrial tachy-cardia with atrioventricular block. Am. J.Med. 25: 442, 1958.

18. HECUT, H. H.: Heart failure and lung disease.Circulation 14: 265, 1956.

19. WHITE, P. D.: Heart Disease. Ed. 4. New York,MIacmillan Company, 1951.

20. CORAZZA, L. J., AND PASTOR, B. H.: Cardiacarrhythmias in chronic cor pulmonale. NewEngland J. Med. 259: 862, 1958.

21. SZENT-GYORGYI, A.: Contraction in the heart mus-cle fiber. Bull. New 'York Acad. Sc. 28: 3,1952.

22. BAUM, G. L., DICK, M. M., BLUM, A., KAUPE, A.,AND CARBALLO, J.: Factors involved in digi-talis sensitivity in chronic pulmonary insuffi-ciency. Am. Heart J. 57: 460, 1959.


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LEONARD W. RITZMANNLEONARD M. GOLDBERG, J. DAVID BRISTOW, BRENT M. PARKER and

Association with Chronic Pulmonary DiseaseParoxysmal Atrial Tachycardia with Atrioventricular Block: Its Frequent

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1960 American Heart Association, Inc. All rights reserved.

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