Stokes-Adams Attacks Research Articles

Congenital complete atrioventricular block: Clinical and electrophysiologic predictors of need for pacemaker insertion

Because an initial Adams-Stokes attack in the patient with congenital complete atrioventricular (A-V) block may sometimes prove fatal, there is a need to be able to identify the patient at great risk of having such attacks. Twenty-four children with congenital complete A-V block were followed up for 1 to 19 years to determine the efficacy of current methods of predicting risk for Adams-Stokes syncope and the usefulness of pacemaker therapy in relieving symptoms. The heart rate at rest, configuration of surface electrocardiographic complexes, data obtained during intracardiac electrophysiologic study and response to graded treadmill exercise testing were compared in children with and without syncope. One or more Adams-Stokes episodes were experienced by eight children, one of whom died. Only a persistent heart rate at rest of 50 beats/min or less demonstrated any significant (probability [p] < 0.01) correlation with the incidence of syncope. Intracardiac electrophysiologic study was of little benefit because the site of block did not correlate with syncope. Although the increase in heart rate during treadmill exercise testing showed no correlation with prevalence of syncope or location of block, exercise-induced ventricular ectopic beats may have predictive value in older children and young adults. Ventricular pacemakers were implanted in 10 children. Each child was asymptomatic over a 1 to 10 year follow-up period. Because extreme bradycardia may contribute to the prevalence of Adams-Stokes attacks in children with congenital complete A-V block, careful evaluation of heart rate at rest may be an effective means of differentiating patients at risk of syncope. Pacemaker therapy is a feasible and effective method of treatment in young children and relieves symptoms.

Medical consultation on surgical services: an annotated bibliography.

This bibliography provides a literature base for residents on medical consultation services and for internists performing consultations in a field that is difficult to research through Index Medicus.

Pseudo-Runaway Pacemaker

To the Editor. —Malfunction of a permanent cardiac pacemaker is most often manifested by intermittent or absolute cessation of function or by a reduction from the chronic stable pacing rate. On rare occasions, however, pacemaker tachycardia occurs with rate acceleration up to 100 beats per minute, ie, runaway pacemaker. In this report, pseudo-runaway pacemaker, a previously unrecognized phenomenon, will be presented. Report of Cases.—Case 1. —A 46-year-old woman had a R-wave inhibited demand pacemaker inserted for episodic Stokes-Adams attacks with verified high-degree atrioventricular block. The pacing rate was 72 beats per minute (Figure, A). A routine ECG, taken three months later during an emergency room visit for noncardiac chest pain, showed 100% pacemaker capture at 90 beats per minute (Figure, B). Although the pulse generator was implanted only three months earlier, component failure was suspected, and the unit was replaced. Case 2. —A 70-year-old man had a demand

Review article. Congenital complete heart block.

Isolated congenital complete heart block has a heterogenous aetiology. In approximately one-third of the patients in the present material the mothers had symptoms or signs of connective tissue disease. The mortality is highest in the neonatal period, much lower during childhood and adolescence and increases slowly later in life. There are elderly patients who are completely asymptomatic but patients are also encountered with signs and symptoms of more or less severe myocardial damage. Stokes-Adams attacks may occur at any age. About 10% of patients below 15 years of age in this material and about 25% of those above 15 years (mean age 30 years) were paced. In the neonatal period the predominant indication for pacing was heart failure. It is difficult to make a prognosis in the individual patient. Apart from already known risk factors, a fixed or decreasing low ventricular rate neonatally and a prolonged QT time seem to be bad prognostic signs.

Stokes-Adams attacks due to acute nonspecific myocarditis in childhood.

Six patients aged between 1 to 11 years (4 females and 2 males) developed Stokes-Adams attacks with complete heart block due to acute nonspecific myocarditis. Transvenous pacing was instituted in 2 patients, but in the other 4 patients the ECG returned to normal by isoproterenol. All ECGs in complete heart block showed QRS complexes of right bundle branch block with left posterior hemiblock pattern, except for 1 which showed QRS complexes of complete left bundle branch block pattern. The ECG improved sequentially in order and left anterior hemiblock pattern of QRS complexes remained to the last during the convalescent period. Normal atrioventricular conduction returned by 2 to 24 hours in all but 1 patient who was dead and 1 of the 2 patients with shock. In another patient bifascicular block has persisted.

Clinical and histopathological profile of sarcoidosis of the heart and acute idiopathic myocarditis. Concepts through a study employing endomyocardial biopsy. I. Sarcoidosis.

In addition to our previous reports which are based on the work of the Japanese Sarcoidosis Committee, this communication reports the analysis of expanded case material, evaluation of endomyocardial biopsy in 8 biopsied and 7 autopsied cases, and the effects of steroid and pacemaker therapy. 1. Out of 96 autopsied cases of sarcoidosis, 55 cases have been determined by us as being fatal myocardial sarcoidosis. Additionally, analysis of sarcoidosis patients who were clinically assessed as having cardiac dysfunction was made through the literature and in 17 cases a questionnaire review of the reported cases in Japan was made. It was noted that out of a total of 72 cases, there was a high incidence of cardiac sarcoidosis (fatal myocardial sarcoidosis + sarcoidosis with cardiac dysfunction) in 40-59 year-old women. 2. The modes of cardiac death in fatal myocardial sarcoidosis in 55 cases were: sudden death 20 cases (36.4%); congestive heart failure 10 cases (18.2%); arrhythmia 9 cases (16.4%): Adams-Stokes Syndrome (except sudden death) 8 cases (14.5%); cardiogenic shock 1 case (1.8%); pacemaker death 1 case (1.8%); pulmonary infarction 1 case (1.8%) and unknown 5 cases (9.1%). 3 . Expectancy of a definite diagnosis of endomyocardial biopsy which was made by an imitation endomyocardial biopsy in 7 autopsied cases of fatal myocardial sarcoidosis was 62.8% from the right ventricle and 46.9% from the left ventricle. When such pathology as a distinct scar or acute inflammatory change is incorporated, the possibility of the usefulness of the biopsy increases. Examples of 8 biopsied cases were shown. 4. Ultrastructural findings of epithelioid cells and giant cells in a case of a 42-year-old female in whom endomyocardial biopsy was performed from the right ventricle were described. 5. Our view on the nature of giant cell myocarditis was discussed. This is not a disease entity but a histopathological entity. 6. Evaluation of steroid therapy in cases with fatal myocardial sarcoidosis and with cardiac dysfunction revealed that it was effective in 5 out of the 14 cases of the former group (35.7%), and 10 out of the 14 cases of the latter group (71 .4%). 7. Pacemaker implantation, either temporary and/or permanent, was made in 9 of the 55 cases (16.5%) of fatal myocardial sarcoidosis and in 6 of the 17 cases (35.5%) of sarcoidosis with cardiac dysfunction. In the former group, the pacemaker was effective for a certain period of time but finally death occurred. In the latter group, pacemaking was effective.

Two cases of chronic and acute myocarditis with Adams-Stokes attack

Two cases of chronic and acute myocarditis with Adams-Stokes attack

Arrhythmias in primary pulmonary hypertension.

Through the examination of 171 electrocardiograms (ECG) of 101 patients with primary pulmonary hypertension (PPH), the following conclusions were obtained. Arrhythmias were found in 27 (26.7%) of the 101 patients. Among the surviving cases, arrhythmias were found in 8 (17.8%) out of 45 patients, but among the decreased cases, the figure was higher, 19 (33.9%) out of 56. There were instances of more than one kind of arrhythmias in the same patient and a total of 34 types of arrhythmias were noted. The main types of arrhythmias were sinus tachycardia (13 cases), sinus bradycardia (6 cases), and first degree A-V block (5 cases), which accounted for 70% of the total. Sinus tachycardia was observed in only 2 of the survivors but in 11 of the decreased cases, which showed a significant difference (p less than 0.05). First A-V block were all induced by digitalis. Wenckebach type of second degree A-V block was noted in only 1 case and it was also induced by digitalis. Since severe attacks of ventricular arrhythmias were very rare in these cases with PPH, it is difficult to consider the Adams-Stokes syndrome as the cause of syncopal attacks or sudden death. However, it is necessary to further investigate nodal functions by means of continuous ECG monitoring, the overdrive suppression test and His bundle ECGs.

Cutaneous reaction to an epoxy-coated pacemaker

Cutaneous reactions to implanted materials occur, but implanted cardiac pacemakers rarely have been suspected as the triggering agent. Raque and Goldschmidt¹described a patient with circumscribed eczematous dermatitis occurring over the site of a pacemaker within three weeks of implantation. Later, widespread nummular eczema developed. The authors discussed whether it was an irritant dermatitis due to a medicalgrade silicone elastomer or nummular eczema provoked by an irritant dermatitis. Patch tests in a patient and two control subjects with the uncured silicone adhesive gave positive reactions that were thought to be irritant reactions. The patient's dermatitis improved even though the pacemaker was not removed. Recently I suspected a patient to have "pacemaker dermatitis." The cause relationship seemed clear, but the mechanism did not. <h3>Report of a Case</h3> A 65-year-old man with Stokes-Adams syndrome had an epoxy-coated pacemaker (Medtronic) implanted subcutaneously in the right infraclavicular region in December 1975. There was

Cutaneous Reaction to an Epoxy-Coated Pacemaker

Cutaneous reactions to implanted materials occur, but implanted cardiac pacemakers rarely have been suspected as the triggering agent. Raque and Goldschmidt¹described a patient with circumscribed eczematous dermatitis occurring over the site of a pacemaker within three weeks of implantation. Later, widespread nummular eczema developed. The authors discussed whether it was an irritant dermatitis due to a medicalgrade silicone elastomer or nummular eczema provoked by an irritant dermatitis. Patch tests in a patient and two control subjects with the uncured silicone adhesive gave positive reactions that were thought to be irritant reactions. The patient's dermatitis improved even though the pacemaker was not removed. Recently I suspected a patient to have "pacemaker dermatitis." The cause relationship seemed clear, but the mechanism did not. <h3>Report of a Case</h3> A 65-year-old man with Stokes-Adams syndrome had an epoxy-coated pacemaker (Medtronic) implanted subcutaneously in the right infraclavicular region in December 1975. There was

Arrhythmias and Stokes-Adams Attacks in Acute Rheumatic Fever

In the same issue an error was made in the article "Arrhythmias and Stokes-Adams Attacks in Acute Rheumatic Fever" by Lenox et al. (Pediatrics 61:599, April 1978). In the Table on page 601, under "Comments &amp; Treatment," the words "paced every. . ." should be replaced by "paced for. . . ."

Arrhythmias and Stokes-Adams Attacks in Acute Rheumatic Fever

In spite of general complacency about first-degree heart block in acute rheumatic fever, abnormal conduction with dysrhythmias, occasional complete heart block, and, rarely, Stokes-Adams attacks are important early signs of acute rheumatic fever and may precede other signs. Every person with episodic fainting is entitled to an ECG, and frequent ECGs are imperative in any case of rheumatic fever with signs of arrhythmias. Changing atrioventricular block necessitates continuous monitoring for dysrhythmias. A 13-year-old boy who appeared with Stokes-Adams attacks secondary to acute rheumatic fever was successfully treated by temporary pacing.

Sick Sinus Syndrome

The describes a rather heterogeneous group of patients whose presenting symptoms are primarily cerebrovascular in nature (Stokes-Adams attacks, dizziness, and cerebrovascular accidents). The principal pathophysiological disturbance is node dysfunction characterized by bradyarrhythmias (sinus bradycardia, sinoatrial block, arrest) with or without associated tachyarrhythmias (tachycardia-bradycardia syndrome).1An interest in and an awareness of this is mandated by the frequency of these complaints. Historically, the first causal relationship delineated was between Stokes-Adams attacks and bradycardia and sinoatrial block.2-4Later in 1954 Short5described syncope in patients with alternating bradyarrhythmias and tachyarrhythmias. Lown6actually coined the term sick sinus to describe a group of patients in whom, after electrical cardioversion, chaotic atrial activity, bradycardia, ectopic beats, and atrial and nodal tachycardia developed. Ferrer7ultimately grouped these patients with diverse symptoms and dysrhythmias together under the general heading sick syndrome in

Long-term follow-up after cardiac pacing in bradyarrhythmias.

Fifty-nine patients aged 39-80 years underwent implantation of a cardiac pacemaker and were followed for up to 9 years (average duration of pacing 39 months). Atrioventricular conduction disturbances (complete atrioventricular block, 2 : 1 atrioventricular block, bifascicular block, and atrial fibrillation with slow ventricular rate) were present in 49 patients and sick sinus syndrome (sinus arrest or sino-atrial block, and bradycardia-tachycardia syndrome) in 10. Pacing was required because of Adams-Stokes attacks in 41 patients, 2 of whom also had congestive heart failure. It was required in 6 because of frequent dizziness, in 10 because of congestive heart failure, and in 2 because of low cardiac output. The symptomatic improvement after cardiac pacing was well recognized in most of our patients, and 32 (54 percent) of the 59 patients pursued normal physical and daily activity. Although the efficacy of pacemaker therapy was of limited value in some patients with congestive heart failure or underlying or coexisting diseases, the beneficial effects following pacemaker implantation were: (1) abolishment of transient neurologic symptoms such as Adams-Stokes attack, (2) relief from a constant fear of a recurrence of an Adams-Stokes attack or sudden cardiac death, and (3) improvement in restricted physical activity due to low cardiac output. Thus, we conclude that pacemaker implantation in most patients with bradyarrhythmias is beneficial not only for the treatment of the acute problem but also because it prolongs life and greatly enhances its quality. However, in spite of the beneficial effects after pacemaker implantation, we still observe a number of complications connected with the use of a permanent pacemaker. Therefore, our policy is to implant a permanent pacemaker following the execution of sufficient studies of the bradyarrhythmia and the etiology of symptoms, and then under taking long-term follow-up of the patients.

A case of rest angina pectoris with ST segment depression and recurrent Adams-Stokes syndrome during anginal attack

A case of rest angina pectoris with ST segment depression and recurrent Adams-Stokes syndrome during anginal attack

The Natural History of Long-Term Cardiac Pacing

During the past ten years, 504 patients have received one or more pacemakers for complete heart block or other arrhythmia. Of these patients, 306 (61%) are alive. Actuarial analysis shows a steady attrition of 9.4% per year for the first five years, decreasing to 7% per year for the second five years. The overall survival was decreased for patients with congestive heart failure and advanced age and was not affected by the history of Stokes-Adams attacks, initial pulse rate below 50 per minute, or a QRS duration greater than 0.12 second prior to pacing. Cardiac problems were the primary cause of death in 71% of the patients. The natural history of patients with permanent pacemakers depends, more than any other factor, on the function of the left ventricle.

Postoperative complete heart block in 64 children treated with and without cardiac pacing

Between 1957 and 1973, a total of 64 children had complete heart block during intracardiac surgery were treated by one of three methods: (1) No pacemaker: Six of the 13 patients in this group had reversion to sinus rhythm. Seven patients continued to have complete heart block, and five of these died of Stokes-Adams episodes. Two patients continue to have complete heart block without pacemaker insertion. (2) Temporary pacemaker: Seventeen of 25 patients had reversion to sinus rhythm and the temporary pacemaker was removed; the other 8 continued to have complete heart block. Five of the eight died--three of Stokes-Adams episodes and two at the time of cardiac reoperation. Three remain asymptomatic without placement of a permanent pacemaker. Six died of postoperative complications unrelated to heart block or pacemaker implantation. None of the other 20 experienced Stokes-Adams attacks. There was one late death in this group. Although there are problems in using permanent pacemakers and electrode systems, in these patients with operatively induced complete heart block their use was associated with a low mortality rate.

Clinicopathological study of fatal myocardial sarcoidosis.

Presented here was an outline of fatal myocardial sarcoidosis in Japan based on 42 autopsy cases. The incidence, clinical features, pathological findings (particularly the distribution of sarcoid lesions in various organs, and gross as well as histological patterns have been reviewed. The ratio of fatal myocardial sarcoidosis to the total number of sarcoidosis deaths is higher than that of other countries and it appears characteristic of Japanese sarcoidosis that the disease occurs here predominantly after the fourth decade in females. Only 12% of myocardial sarcoidosis cases are diagnosed exactly. Conduction disturbances and dysrhythmias due to myocardial damage are its most common manifestations. The modes of presentation or cardiac death are sudden death, 16 cases (41%); congestive heart failure, 9 cases (23.1%); Adams-Stokes syndrome, except sudden death, 7 cases (17.9%); death due to dysrhythmia, 6 cases (15.4%); and 2 pacemaker deaths among the application of pacemakers, 7 cases. As for the ECG findings, A-V block and bundle-branch block was observed in most cases and ectopic beats were also frequently observed. The difficulty in exact diagnosis of myocardial sarcoidosis appears to be due to the frequency of lack of manifestation of systemic sarcoidosis as well as insidious cardiac involvement. The gross findings on myocardial lesions showed 3 patterns and each of the localized patterns corresponded to the histological extension. The conglomerate-band-like pattern corresponded to expansive invasion, the dendrite pattern to interstitial extension. The histological findings on the myocardial lesions were classified into four types: 1) exudative type, 2) granuloma type, 3) combined type of granuloma and fibrosis, 4) fibrotic type. Two extreme cases showed the exudative and fibrotic type, respectively, and were discussed.

Myotonia dystrophica: Ventricular arrhythmias, intraventricular conduction abnormalities, atrioventricular block and Stokes-Adams attacks successfully treated with permanent transvenous pacemaker

In a patient with myotonia dystrophica multiple ventricular arrhythmias and high degree atrioventricular block requiring a permanent pacemaker developed. Patients with skeletal muscle disease may present with disproportionately advanced manifestations of associated cardiac disease. Early recognition of potential serious underlying cardiac disease is important in patients with this condition.

Letter: Stokes-Adams attacks in myasthenia gravis: a possible cholinergic side effect.

The cause of sudden death, which occurs in about one third of myasthenia gravis deaths, is not known. 1 We report a myasthenia patient who had Stokes-Adams attacks that responded to a reduction in anticholinesterase dosage. This probable cholinergic side effect has not previously been reported, to our knowledge, and could account for some cases of sudden death in this disease. Report of a Case.— A 31-year-old white woman had had myasthenia gravis since age 17, requiring several hospitalizations for respiratory failure. Thymectomy had been refused. Estrogen therapy, started because of a menstrual relationship to crises, resulted in improved control. Systemic lupus erythematosus (SLE) was suspected because of a positive antinuclear factor. In March 1973, she was found to be hypertensive (180/125 mm Hg) and began to have several brief blackouts each week, regardless of posture and occasionally accompanied by extensor rigidity and upward eye deviation. Because of the hypertension