Stokes-Adams Attacks Research Articles

Editorial: Aldosterone, potassium and acidosis.

In 1957 in the pages of the Journal, Hudson and his colleagues reported the case of a patient with Stokes-Adams attacks and hyperkalemia who also had inappropriately low levels of aldosterone in th...

Prognosis of Patients with Complete Heart Block or Arrhythmic Syncope

This paper reports the results of a retrospective study carried out with special reference to the survival rate in a series of 101 selected cases including patients with complete heart block (CHB) combined or not combined with Adams-Stokes attacks and patients with arrhythmic syncope without ECG evidence of CHB. All these patients were treated in our Department during 1958-68, none being artificially paced. Twenty-seven patients were alive at the end of the follow-up, i,e 6-15 years after admission to this Department on account of syncopal episodes or CHB. The survival rate--higher in females than males--was lower in the cases of CHB combined with Adams-Stokes attacks than in the cases of asymptomatic CHB. This applied also to the instances in which a complicating disease such as ischaemic heart disease (IHD), hypertension, diabetes, digitalis intoxication or cardiac enlargement coexisted. The survival rate in the 68 cases of CHB was higher at one year (68%) as well as at 5 years (37%) than that reported by other investigators. When assessing the survival rate in cases treated with artificial pacemakers, it is important to study the individual case histories with special reference to a previous or coexisting condition such as IHD, hypertension, diabetes or the presence of cardiac enlargement. The present results support the view that the indications for treatment with artificial pacing should be wide, albeit that the prognosis in this series was more favourable than might have been anticipated from observations by others.

The Tachycardia-Bradycardia Syndrome

The tachycardia-bradycardia syndrome (paroxysmal atrial fibrillation, flutter, or tachycardia followed by sinoatrial block or sinus arrest resulting in Stokes-Adams attacks) is an important clinical entity that requires familiarity by the clinician. Pathologic studies and physiologic mechanisms as revealed in the electrocardiogram indicate multiple disturbances in the conduction system of the heart (sinus node, atria, and atrioventricular junctional tissues). The electrocardiogram establishes the diagnosis. Pacemaker implantation with supplementary drugs has provided a satisfactory means of therapy. With proper treatment the prognosis of patients with the tachycardia-bradycardia syndrome has improved to the extent that the primary determinant of mortality is no longer the arrhythmia, but the underlying cardiac and/or systemic pathology.

A Case of acute diffuse interstitial myocarditis (Fedler's myocarditis) with Adams-Stokes syndrome which showed pathological changes in the conducting tissue on serial method at necropsy

A Case of acute diffuse interstitial myocarditis (Fedler's myocarditis) with Adams-Stokes syndrome which showed pathological changes in the conducting tissue on serial method at necropsy

Multifascicular block in cardiomyopathy. Incidence, localization by His bundle study and prognosis.

Of 70 patients with cardiomyopathy, nine (13%) had bifascicular block: right bundle branch block with left anterior hemiblock in four, right bundle branch block with left posterior hemiblock in two, and left bundle branch block with left anterior hemiblock in three. Isolated left bundle branch block was present in four, isolated left anterior hemiblock in 13, and isolated left posterior hemiblock in one. No isolated right bundle branch block was found. Five of the patients with bifascicular block were evaluated by His bundle electrocardiography and atrial pacing. Block in the His-Purkinje system (prolonged HV interval) was present in four and atrioventricular conduction (AH interval) was normal in all five. Despite a common prolongation in intraventricular conduction, short term prognosis seems to be favorable since: (1) none had spontaneous progression to more advanced block or experienced Stokes-Adams attacks for an average follow-up period of at least 42 months, and (2) with atrial pacing, one-to-one atrioventricular conduction persisted to rates up to 150/min in all patients with no further prolongation of HV interval.

Variant angina pectoris: Report of a case with recurrent Adams-Stokes attacks in the nighttime.

Variant angina pectoris: Report of a case with recurrent Adams-Stokes attacks in the nighttime.

Life-threatening arrhythmias before and with cardiac pacing, and the reliability of the cardiac pacemaker

Permanent cardiac pacing was introduced clinically in 1957 by Weirich, Gott and Lillehei to prevent Adams-Stokes attacks and sudden death due to heart block. Since then, the number of pacemaker patients has steadily increased. In a world survey in 1972, [9] the number of first pacemakerimplantations varied between 30-140 per million inhabitants in different countries. In the USA and Canada, the number of pacemaker patients was 125 000.

Complete heart block. Studies of atrial and ventricular pacemaker site and function.

Atrial and ventricular pacemaker function was studied in 20 patients with idiopathic chronic complete heart block using the rate response to an intravenous bolus dose of isoprenaline (5 mug/70 kg bodyweight). Pacemaker responses were compared with those of 16 normal control subjects. None of the patients was having syncopal attacks at the time of admission and they were therefore selected in that none required immediate pacing. Ten of the patients had His bundle electrograms; all were shown to have a pre-His type of atrioventricular block. Two major groups emerge from the responses to isoprenaline. (a) High risk group: 11 of the 14 patients with reduced ventricular pacemaker responses had frequent syncopal attacks; 8 of the patients with Adams-Stokes syncope had a bundle-branch block pattern, while 3 had a narrow QRS. These patients require pacing. (b) Low risk group: a low risk asymptomatic group (5 patients) was identified with atrial and ventricular responses to isoprenaline within normal range. One of these patients had a bundle-branch block pattern, while 4 had a narrow QRS. These patients might be managed without pacing. The atrial response to isoprenaline was reduced in 12 of the 20 cases, 10 of whom also had reduced ventricular responses. All 9 patients with bundle-branch block had reduced ventricular responses, while 7 had reduced atrial responses. This evidence indicates that cardiac conducting tissue pathophysiology is widespread in complete heart bolck. The present work suggests that consideration of the ventricular pacemaker function is important in assessing liability to syncope in complete heart block. While patients with Adams-Stokes attacks require pacing it is suggested that all asymptomatic patients with complete heart block and those with minor symptoms are assessed using studies of both ventricular pacemaker function and site. A low risk group not requiring a pacemaker may emerge after sufficient follow-up assessment.

Gallbladder Disease and the Cardiac Status

FOR YEARS clinicians have suspected some connection between gallbladder disease and certain cardiac disorders. Varied experiences have suggested an association significant enough to justify cholecystectomy as hopeful therapy for angina pectoris and paroxysmal atrial tachycardia. For others, the only important interrelationship concerns problems of bedside differential diagnosis. The whole matter is in need of clarification. These things are known with reasonable confidence (Friedman's 1 review is recommended): In some patients, removal of a diseased gallbladder is followed by disappearance of long-standing, periodic premature ventricular contractions. In some patients, removal of a diseased gallbladder is followed by disappearance of anginal attacks. It has been reported on several occasions that removal of a diseased gallbladder has been followed by disappearance of Adams-Stokes attacks. No statistical relationship can be found between cholesterosis of the gallbladder and coronary artery disease. During gallbladder surgery, when the gallbladder or cystic duct is already distended, the manipulations

Stokes-Adams attacks due to acute nonspecific myocarditis

Ten patients, all below 30 years of age (8 females and 2 males) developed Stokes-Adams attacks from complete heart block due to acute nonspecific myocarditis. Coexisting thyrotoxicosis was present in two patients and cardiogenic shock was seen in four. Temporary transvenous pacing was instituted in all but one patient. Except for two patients who developed permanent complete heart block, normal A-V conduction returned in between 1 to 12 hours after ventricular pacing in seven patients and after 12 hours of isoprenaline therapy in the final patient. The ECG returned to normal in six patients and all 10 patients survived their acute illness.

Advanced heart block aggravated by carbamazepine.

This report presents a serious adverse reaction to the anticonvulsant compound carbamazepine. A woman was admitted to hospital for recurrent attacks of syncope. She suffered from atrioventricular block of the Mobitz type II. Carbamazepine suppressed the conduction in her already defective Purkinje fibres and induced ventricular stand-still with subsequent Adams-Stokes attacks.

Return of normal conduction after paroxysmal heart block. Report of a case with major discordance of electrophysiological and pathological findings.

This report describes a 52-year-old male with paroxysmal heart block as well as left and right bundle branch block, resulting in Stokes-Adams attacks. The patient experienced a return to 1:1 atrioventricular (A-V) conduction with narrow QRS within 48 hours of the attacks and heart block never recurred. Electrophysiological studies three weeks later revealed a narrow QRS, a normal H-V interval (36 msec), 1:1 A-V conduction up to an atrial paced rate of 210 beats/min, and normal refractory periods with atrial extrastimulus techniques (His-Purkinje system refractory periods less than 370 msec). The patient died from a cerebral embolus incurred during diagnostic left heart catheterization two days after electrophysiological studies. Postmortem examination revealed calcific aortic stenosis with calcific impingement upon the pars membranacea resulting in compression of the distal His bundle and marked disruption of the proximal portions of both bundle branches. This report documents a major limitation of electrophysiological studies, this limitation being that these studies may be totally normal on one occasion in a patient with pathologically significant chronic conduction disease, which may become clinically manifest on another occasion.

Overdrive suppression in diagnosis of sick sinus syndrome

A criterion to determine the indication for pacemaker implantation in the sick sinus syndrome by overdrive suppression is proposed. Overdrive suppression was performed in 10 patients with the sick sinus syndrome (SSS) and another 10 patients with normal sinus rhythm (NSR) who served as controls. In the SSS group, 9 patients had complained of such severe symptoms as Adams-Stokes attack and/or congestive failure and were referred to our laboratory for pacemaker implantation. One other patient, an apparently robust young man (20 years old) referred for detailed cardiac examination, had no remarkable symptoms except for arrhythmias, but was found dead two months later. Atrial pacing for overdrive suppression was carried out at first at various rates ranging from 60 to 180 beats/min for 15 sec, and then at a rate of 100 beats/min for various durations ranging from 5 to 180 sec. After cessation of the atrial pacing, asystolic pauses were measured and the maximum (maximum pause) among the pauses obtained was used as a parameter indicating depression of cardiac automaticity. The maximum pause in the SSS group ranged from 5.6 to 9.0 sec (mean +/- SD = 7.0 +/- 1.2), WHILE THOSE IN THE NSR group ranged from 0.7 to 1.5 sec (mean +/- SD = 1.2 +/- 0.14). Therefore, the maximum pause was considered not only to reflect the severity of the symptoms necessitating pacemaker implantation in the 9 patients of the SSS group but to have warned us of sudder death in another patient. We concluded that overdrive suppression is useful as a supplementary challenge to determine indications for pacemaker implantation for the sick sinus syndrome, and that prolongation of the maximum pause beyond 5.0 sec is the critical level for pacemaker implantation.

Adams-Stokes attack probably due to toxoplasmosis.

Adams-Stokes attack probably due to toxoplasmosis.

Management of Postoperative Complete Heart Block in Infants and Children

Surgically induced complete heart block (CHB) occurred in 40 (9 percent) of 425 infants and children who underwent intracardiac repair of congenital heart disease. Thirteen patients died in the immediate postoperative period from causes other than CHB, and there was one late death following a Stokes-Adams attack. Among the 26 survivors, 18 reverted to a sinus rhythm and eight patients required permanent cardiac pacing. The complications of permanent cardiac pacing were numerous; yet all eight patients survived and enjoyed normal activities up to five years after surgery. A new method of managing postoperative CHB in infants and children has been presented.

Perforation of the Tricuspid Valve by a Transvenous Pacemaker

FOR the past 12 years, permanent and temporary transvenous cardiac pacing has become not only an accepted, but an indispensable and many-pronged tool. It has been used extensively in the treatment of the Adams-Stokes syndrome, and in patients with symptomatic bradyarrhythmia with or without a myocardial infarction. Recently, electrical pacemakers have been employed to override life-threatening arrhythmia refractory to pharmacologic approaches. 1 Currently, permanent cardiac pacing is usually accomplished with the insertion of an endocardial electrode through a peripheral vein. Although this approach has simplified pacemaker insertion, various complications can develop. Displacement of the catheter electrode has been reported in all large series and has had an incidence of displacement of 10% to 15%. 2,3 Other complications include disruption of the electrode, 4 atrial thrombi, 5 air embolism, 3 endothelization of the catheter, 6 phrenic nerve stimulation, and myocardial perforation. This report describes the perforation of a tricuspid value. Report

Adams-Stokes Attacks Associated With Hysteria

A SERIOUS case of heart disease went undetected during 18 months of misadventure because of a confusing mixture of psychogenic convulsions and Adams-Stokes attacks. These may have been more than coincidentally related. <h3>Report of a Case</h3> A 55-year-old female textile worker was admitted in April 1970 with a history of three unusual attacks during the previous nine months. On each occasion, after a sudden failure of vision she became dyspneic and collapsed. Many attacks were associated with climbing stairs or other vigorous movements. Her father had had grand mal epilepsy. The results of her general and neurologic examinations were normal, but when asked to do the Barré test she trembled, fell to the right, and closed her eyes. She was able to remember test phrases and was abruptly alert in two minutes, complaining that this happens when she tries to work. She was discharged with a diagnosis of psychogenic convulsions.

Adams-Stokes attacks associated with hysteria

Adams-Stokes attacks associated with hysteria

Cardiac Lesions in Secondary Oxalosis

The significance of calcium oxalate deposition in the myocardium was studied at autopsy in 21 patients with renal insufficiency. The oxalate crystals in the myocardium frequently were associated with focal necrosis and marked fibrosis. Of seven patients with severe oxalate deposits, six had extensive myocardial fibrosis. Four of these six had severe, intractable congestive heart failure. One had complete heart block and Stokes-Adams attacks, and at autopsy oxalate crystals were observed in the cardiac conducting system. These observations suggest that myocardial oxalosis is another potential complication of renal insufficiency and that oxalate-induced myocardial abnormalities may contribute to congestive heart failure and conduction abnormalities in patients with uremia.

Pacemaker Electrode Break: Emergency Treatment

To the Editor.— Since the advent of electrical pacing of the heart, many unusual causes of malfunction have been recognized. This report also describes an unique emergency maneuver. Report of a Case.— A 70-year-old farmer had a left ventricular epicardial pacemaker implanted eight years ago. The generator pocket was in the upper abdomen, and the electrodes crossed the belt region in a subcutaneous tunnel. A few months later, the patient was brought to the emergency room because of repeated Stokes-Adams attacks particularly when in the supine position. His family noted that he had no syncopal episodes throughout the two-hour journey by car while in the sitting position. In the emergency room, he lost consciousness while supine, and ventricular standstill was recorded on his electrocardiogram. Sitting him forward or pressing his abdomen at the waist above the electrode, resulted in immediate resumption of electrical pacing. This was confirmed repeatedly under electrocardiographic