Paroxysmal ventricular tachycardia in the absence of demonstrable heart disease∗

Paroxysmal Ventricular Tachycardia in the Absence of Demonstrable Heart Disease* THOMAS E . 11AIR, JR ., M .D ., JOHN T . EAGAN, M .D . and EDWARD S . ORGAtN, M .D .

Durham, North Carolina

ventricular tachycardia is a serious, frequently fatal, arrhythmia, most pA commonly observed in the presence of underlying organic heart disease . Its occurrence and favorable prognosis in patients without other signs of heart disease are less well appreciated . It is the purpose of this paper to describe three patients who exhibited paroxyscris of ventricular tachycardia in the absence of other detectable signs of heart disease . SROXYSMAL

CAsF. REPORTS

This 31 year old white woman was first seen at the Duke University Medical Center in January 1958 with the chief complaint of "blackout" spells for 8 months . Of interest was a history of episodes of weakness associated with rapid heart action during the ages of 10 to 17 years . These had always occurred after excessive exercise . The patient was then asymptomatic until the first trimester of her second pregnancy in 1955, when she noted episodes of weakness, blurred vision and rapid heart action which lasted only momentarily . 'These did not cause great concern nor did she seek medical attention . Her pregnancy was otherwise uncomplicated . She was free of these attacks until the first trimester of her third pregnancy in May 1957 when, while playing golf, she had an episode of weakness associated with blurred vision . An electrocardiogram, taken later that day, was normal except for frequent premature ventricular contractions . She was given quinidine and over the ensuing 2 months was asymptomatic . In July 1957, while eating lunch, she had a sudden episode of faintness and, upon standing, abruptly lost consciousness for a few seconds . An electrocardiogram taken a few minutes later revealed ventricular tachycardia (Fig . 1) which reverted to normal rhythm spontaneously . Quinidine therapy was resumed . CASE 1 .

She delivered a normal infant in November 1957 . In January 1958, quinidine therapy was discontinued . Ten days later she had an episode similar to the one in July 1957 which lasted only 2 to 3 minutes . An electrocardiogram again revealed frequent premature ventricular contractions and the administration of quinidine was resumed . Complete physical examination including the heart was entirely within normal limits . The blood pressure was 100/60 mm . fig . Routine laboratory studies including x-ray films of the heart (Fig . 2) were all within normal limits . Art electrocardiogram was normal except for occasional unifocal premature ventricular contractions (Fig . 1) . 'lhe patient was last seen in December 1960. In the interim she has continued to take quinidine, 0 .2 gm ., four times a day . On occasions she has noted that after drinking an excessive amount of coffee, or when she is quite fatigued, slight frontal headache, blurring of vision and a pounding rapid beat of her heart will develop . After she sits and rests, these clear in approximately half an hour . Repeat examination at this time revealed no abnormalities except for an occasional premature beat. Hyperventilation and carotid sinus pressure produced no symptoms . The electrocardiogram was unchanged and confirmed the presence of unifocal premature ventricular contractions of the same configuration as those noted previously . 'These were increased in number after mild exercise . Comment : This case is of unusual interest because of documented paroxysms of ventricular tachycardia occurring in a woman with no evidence of heart disease . From the history these may have been present at an early age . Symptoms suggesting their exacerbation during pregnancy are of note . These episodes have been reasonably well controlled with orally administered quinidine . The clectrocardio-

* From the Department of Medicine, Duke University School of Medicine, and the Cardiovascular Disease Service, Duke University Medical Center, Durham, North Carolina . This investigation was supported (in part) by a grant from the Life Insurance Medical Research Fund, and by a research grant, H-4807, and a training grant, HTS-5369, from the National Heart Institute, Public Health Service . FEBRUARY 1962

209

210

Hair . Eagan and Orgain

Fm . 1 . Case 1 . Note similarity of complexes during episode of ventricular tachycardia (lead Or, below) to the isolated ventricular contraction in the same lead and in lead III Of the tipper tracing . Fte. 3 . Case 2 . 'the routine tracing shoes bigcminaI rhythm . Note similarity of complexes in lead i and V2 (below) during a bout of ventricular tachycardia to the premature ventricular contractions in the respective leads of the upper tracing .

occurring later in the same tracing, and in the same lead in another tracing . CAST; 2 . This 29 year old white male college professor was seen at the Duke Lnivemily Medical Center in February 1958 for follow-up examination . He was seen here for the first time at the age of 14 . A slow pulse with coupling had been noted 1 Year previously by his family physician . Examination at that time was within normal limits except for bigeminy and questionable fullness Of the left ventricle on fluoroscopic examination . It was observed that ventricular taehycardia developed when he assumed the recumbent position, and itrut ediatelyceased when he sat up (Fig . 3) . Paroxysmal ventricular tachvcardia could be produced by exercise . Quinidine was recommended but was not taken by the patient, apparently because of lack ofsymptoms, Over the ensuing years he led a rather sedentary Fig . 2 . Case 1 . Tel coroentgenngram of chest .

gram (Fig . 1) during the arrhythmia is characteristic of ventricular tachycardia . There are slight irregularity and deformity of the ventricular complexes . The complexes during the taehycardia are similar to an isolated complex

life, avoiding strenuous exercise . He continued to note a slow pulse rate but with a noticeableincreaseon exercise . He denied symptoms except that he related two episodes of quite rapid heart ac don occurring over the past several years . Both had occurred at night, awakening him from his sleep and lasting about 30 seconds . On repeat examtnatime nothing abnormal was noted THE AMERICAN JOURNAL OF CARDIOLOGY

Paroxysmal Ventricular Tachycardia

Fro . 4.

Case 2 .

Teleoroentgenogram of chest .

except for premature ventricular contractions producing bigeunny . The heart rate was 80 per minute at the apex, 40 per minute at the wrist . A chest x-ray film (Fig. 4) and routine laboratory studies were within normal limits . After 50 hops the premature ventricular contractions cleared with the development of a sinoauricular tachycardia . After a few minutes of rest the rate slowed with the development of frequent premature ventricular contractions of the sane configuration as noted previously, producing coupling (Fig . 3) . Comment : This case was of unusual interest because of the patient's age at the onset of cardiac irritability and the long follow-up period without the development of signs of underlying heart disease . Also of note was the rather slow rate (125 beats per minute) during the paroxysm of ventricular tachvcardia . The electrocardiogram (Fig . 3) revealed complexes during the tachycardia having the same configuration as the ectopic complexes in the respective leads of the routine tracing . That this was truly ventricular tachycardia was evidenced in multiple tracings revealing its onset and termination, which unfortunately we no longer have . Cnsx 3 . This 52 year old white man stated that 2 years previously, while sitting some 30 minutes following a full meal, he suddenly experienced a peculiar sensation of fullness substernally associated with pounding in his cars and gradual loss of consciousness . These spells recurred every 10 to 15 minutes over a period of approximately 1 hour . Each attack was estimated to last only a few seconds . Following this FEERPARV

1962

Fro. 5 .

Case 3 .

21 1

Teleoroentgenogranr of chest .

episode, except Ow a brief illness diagnosed as influenza, he was completely asymptomatic and worked full time . His job as personnel manager placed him under considerable emotional stress and tension . Approximately 1 year following this episode, he experienced the second attack which was similar in character. He was again asymptomatic for 6 months . Then, while he parked his car, the third episode developed ; this lasted over a period of some 20 minutes with variations in level of consciousness . From this point until he was seen at the Duke University Medical Center in November 1959, repeated episodes occurred, each apparently precipitated by emotional stress or exertion . There was no history of hypertension, convulsive disorder, angina pectoris or congestive heart failure . The patient had smoked rather heavily until July 1959 when he stopped altogether . Coffee was used but no alcoholic beverages . Family history was noncontributory . Examination revealed a well developed and well nourished man in no distress . His blood pressure was 160/100 ram . Hg, pulse 78 and regular . No abnormal findings were noted . Hyperventilation and carotid sinus pressure failed to reproduce his symptoms. All laboratory studies were within normal limits . A chest film revealed a normal sized heart and bilateral hilar calcification (Fig. 5) . The resting electrocardiogram was normal . Following exercise, bursts of ventricular tachycardia at a rate of 250 beats per minute developed (Fig . 6) . These gradually subsided after several minutes, with rest. A repeat exercise test again precipitated ventricular tachycardia, occurring in paroxysms which required the intravenous administration of procaine amide for conversion to normal rhythm . Following discharge the patient continued to

212

Hair, Eagan and Orgain

Flo . 6 . Case 3 . Above, resting tracing. Belszc, l .cwis lead showing premature ventricular contractions and a run of ventricular tachycardia . Note similarity of all the ertopic' umpleccel take procaine amide, 500 mg, every 4 hours ; however, episodes of tachycardiaa continued, perhaps more frequently . Medication was changed to quinidine, 0.2 gin . four times a day ; since then he has felt well . He has resumed moderately heavy work on a full schedule . He has continued to take quinidine for over a year and there have been no further attacks . Comment : This case was of unusual interest because of the relation of attacks to exertion and emotional stress . Also of note was the absence of palpitation during any of the episodes of tachycardia . Although no organic heart disease could be demonstrated, asvmptomatic coronary disease is a possibility which cannot lie excluded . 'The electrocardiogram (Fig . 6) is characteristic of ventricular tachycardia . There are isolated premature ventricular contractions, with compensating pauses, of the same form as in the bout of tachycardia . There are slight irregularity and deformity of the ventricular complexes . The tachycardia begins with an abnormal complex . COMMENTS

Paroxysmal ventricular tachycaLUtta most frequently occurs in the setting of a recent myocardial infarction or severe coronary artery disease .' It may also occur in association with

hypertensive or rheumatic heart disease . The presence of this condition, however, in the absence of demonstrable organic heart disease has been well documented, occurring in 11 to 18 per cent in the larger series .' -' Of interest are the reported cases in which the arrhythmia appeared to be precipitated by emotional strain, exertion and fatigue . 1-9 Orthustatic paroxysmal ventricular tachycardia in an otherwise normal person has been recorded .s In this case the attacks could be precipitated only with the patient in the upright position and were terminated promptly when the patient reclined . The paroxysms could not be reproduced following the intravenous administration of ergotamine, a drug whose pharmacologic action is sympatholytic . It is well known that such factors as emotional stress, excitement, exertion and assuming the upright position arc associated with an increase in sympathetic tone . Its precipitation by the administration of atropine has likewise been demonstrated, the usual precipitating factors having been exercise and excitemeuts'to Note has been trade of the association of paroxysms with excessive intake of beer. ,° cigar smoking-5 and its inure frequent occurrence and duration concomitant with the menstrual cycle ." Clinical Forms and Features : Ventricular tachycardia has been categorized into several clinical forms ." These include : (1) Prefibrillatoryventricular tachycardia which is always associated with myocardial damage or metabolic exhaustion and is nearly always fatal . (2) Curable and mild monomorphic ventricular extrasystoles with paroxysms of tachycardia . This form especially affects young subjects with healthy hearts, is very resistant as a rule to therapy including quinidine, and tends usually to clear as patients become older . One interesting case report's notes the disappearance of tachycardia following the onset of a delayed pubescence, suggesting the possible role of endocrine factors . (3) Paroxysmal ventricular tachycardia due to a lesion of the ventricular septum . (4) Persistent and prolonged ventricular tachycardia developing in sound hearts in young subjects . These patients do not have extrasystoles or short runs of tachycardia . The mechanism of ventricular tachycardia is probably quite similar to that of atrial tachycardia except that the ectopic focus or ring is situated in the ventricle instead of the atrium . The subjective symptoms displayed by patients exhibiting either rhythm disturbance may be THE AMERICAN JOURNAL OF CARDIOLOGY



213

Paroxysmal Ventricular Tachycardia identical although modified by the nature and severity of the underlying pathology . Electrocardiographic Features : The diagnosis of this condition becomes certain only after its demonstration by the electrocardiogram . The criteria by which this is established have been clearly delineated .' , " They include : (1) the identification of P waves during the paroxysm at a rate slower than the ventricular QRS complexes ; (2) a paroxysm of abnormal ventricular complexes, i .e ., three or more at a rapid rate occurring during atrial fibrillation ; (3) the onset of tachycardia with an abnormal ventricular complex ; and (4) a close resemblance, in the same lead, of the isolated QRS complexes of ventricular premature beats to the QRS complexes of the tachycardia . Only one of these conditions is needed to establish the diagnosis of paroxysmal ventricular tachycardia . The occurrence of ventricular complexes transitional in shape to sinoauricular beats (fusion beats) during a bout of paroxysmal ventricular tachycardia has been offered as a diagnostic aid . 14 Supra ventricular tachycardia with aberrant ventricular conduction may be easily confused with

ventricular tachycardia . The onset of this condition is usually preceded by several normally conducted ventricular complexes prior to the development of the intraventricular block . The form of the ventricular complex here is frequently a simple widening of the QRS complex or the configuration of right bundle branch block ." Carotid sinus pressure may result in slowing of the pacemaker in sinoauricular tachycardia or an increase in A-V block, and with intraventricular conduction disturbances, which arc rate dependent, normal ventricular conduction may result, thus clarifying the picture . Ectopic supraventricular tachycardias, with the exception of auricular flutter, are usually not modified in this manner, i .e ., termination may occur but not slowing . The electrocardiographic picture of pseudoventricular tachycardia may present a problem in diagnosis . Knowledge of previous tracings showing accelerated A-V conduction or the Wolff-Parkinson-White syndrome are helpful . Patients with these conditions usually do not present the alarming clinical picture as do those with ventricular tachycardia despite higher ventricular rates . 16 Because the routine electrocardiogram may be quite difficult or impossible to interpret correctly, resort to esophageal leads may be quite useful? 7 Other findings, while strongly suggestive of FEBRUARY

1962

the diagnosis, arc less practical and any or all cannot be considered pathognomonic of ventricular tachycardia . Briefly these include :'- (1) slight irregularity, with rates differing by five to seven beats from minute to minute ; (2) occasional giant waves in the jugular pulses ; (3) changing intensity and quality of the first sound in the presence of tumultuous precordial sounds of low intensity, staccato in type ; and (4) failure of the heart rate to slow on carotid sinus, oculocardiac or other means of reflex vagal stimulation . Prognosis : While ventricular tachycardia is usually of rather short duration, occurring in paroxysms in patients with no organic heart disease, its long continued presence to the point of cardiac exhaustion has been documented (32 days) . 1 s However, a favorable outcome after a prolonged episode (21 days) with conversion has been reported . 19 Caesarian section has been successfully undertaken during a bout of ventricular tachycardia in a patient with no demonstrable cardiac disease in whom the paroxysmal tachycardia began during pregnancy and continued to recur following delivery . 20 Treatment of this condition is directed toward those factors which tend to produce or accentuate autonomic imbalance . Moderation in the use of alcohol, tobacco, coffee, avoidance of overexertion and fatigue, and release of emotional tension undoubtedly are beneficial . Fur prophylaxis against recurrent episodes, quinidine and procaine amide are undisputedly of the greatest value . Dilantin ® has been used with success 21 Prolonged episodes of ventricular tachycardia lead to myocardial exhaustion, an increase in ventricular irritability and the setting for ventricular fibrillation . In this situation, emergency measures are indicated, such as parenteral administration of procaine amide or quinidine . Other drugs which have been employed successfully include intravenously administered 20 per cent magnesium sulfate, calcium chloride or gluconate, potassium salts and morphine . Although digitalis has been generally regarded as contraindicated in this condition, its use after the failure of the measures cited has been advocated 22 SUMMARY

Three cases of paroxysmal ventricular tachycardia in the absence of demonstrable heart disease are presented . Its occurrence and



214

Hair, Eagan and Orgain

favorable prognosis in patients without other signs of heart disease are not well appreciated . Diagnosis of this condition becomes certain only after its demonstration by the electrocardiogram . The identification of P waves clurin, the paroxysm, at a slower rate than the ventricular complexes ; the presence of a paroxysm of abnormal ventricular complexes occurring during auricular fibrillation ; the onset of tachvcardia with an abnormal ventricular cornplex or a close resemblance, in the same lead, of isolated ectopie QRS complexes to the complexes of the tachvcardia are the established criteria for diagnosis . The esophageal lead ma} he of great help . Therapy is directed toward removal of precipitating factors and use of procaine amide or quinidine to suppress the ectopic factors . Established bouts require vigorous attention, i .e ., parenteralh- administered procaine amide or quinidine .

REFERENCES 1 . ARMBRUS'r . C . A ., JR . and LEVINE, S . A . Paroxysmal ventricular rarhycardia . Study of 107 cases . Gradation, 1 : 28, 1950 . 2 . HERRMANN, G . R . . PARKS, II . M . and HrjTMANCIK, M . R . Paroxysmal ventricular tachycardiaclinical and electrocardiographic study . den . Heart J ., 57 : 166, 1959 . 3 . Coors, W . 1' . and WHITE, P . D . Paroxysmal ventricular tachycardia . Rrdt . heart J., 5 : 33, 1943 . 4 . WILSON, F . N ., WISHART, S . \b'., MACLEon . A . G . and RARrccR, P . A clinical type of paroxysmal tachycardia of ventricular origin in which paroxysms are induced by exertion . Am . Heart J . . 8 :155,1932 5 . G¢CHRIsr, A . R . Paroxysmal ventricular tachycardia . Am . 'heart J., t : 546, 1926 . 6 . Ruse, A . and RLANKFEIN . J . : Paroxysmal ventricular tachycardia in an apparently normal heart . .Iat. Med. . 42 : 680, 1955 . Ace 7 . HARVEY, W . P . and LEVINE, S . A . Paroxysmal ventricular tachycardia duo to emotion . Possible mechanism of death from fright. J .A .M.A ., 150 :479,1952 .

8 . PETERS, M. and PENNER, S . L . Orthostatic paroxysmal ventricular tachvcardia . Am . Heart J. 32 : 645, 1946 . 9 . Scc rr, R . W . Observations on a case of ventricular tachycardia with retrograde conduction . Heart, 9 :297,1921 . 10, FREUNOLICH, J . Paroxysmal ventricular tachvcardia . Am . Heart J ., 31 :557 . 1946. 11 . FREMONT, R ., GALLAVARDIN, L . and CoiEN, P . Paroxysmal ventricular tachvcardia . A clinical classification . Brit . Heart . J. . 15 : 172 . 1953. 12 . FRIEDMAN, S ., Asu, R . and KLEIN . 1) . Repetitive paroxysmal ventricular tachvcardia : Report of a case in a child . Pediatricj, 22 : 738 . 1958 . 13 . HERRMANN, G . R . and ROarnsox, G . C . Paroxysmal tachycardia of ventricular origin and its relation to coronary occlusion . H,,,1,8-59 .1921 . 14 . DREsstLR, W . and R OESI .E R . H . The occurrence in paroxysmal ventricular tachycardia of ventricular completes transitional in shape to sinoauricular beats . A diagnostic aid . Am . HemY J ., 44 : 485, 1942 . 15 . PICK, A . and I .ANSENDORF . R . Differentiation of supraventricular and ventricular tachvcardias . Peo,gr. Caedfouarc . Die ., 2 : 391, 1960 . 16 . HFRRMANN, G. R ., OA'TES, J. R ., RuNCE,'I . M . and HEJruANc!K . M . R . Paroxysmal pseudoventricular tachycardia and pscudoventricular fibrillation in patients with accelerated A-V conduction . Am . Heart J ., 53 : 254, 1957 . 17 . KrsTrN, A . D . and BRUCL, J . C . Simultaneous esophageal and standard electrocardiographic leads for the study of cardiac arrhylhmias . Am . Heart J ., 53 : 65, 1953 . 18 . ELLtOI . A . R . and FENN, G . K . Long continued ventricular tachycardia . Report of an unusual case_ Am . Heart J. . 9 : 806, 1934 . 19 . Duuas, A . W. and PARMET . 1) . H . Ventricular tachycardia stopped on the twenty-first day by giving quinidine sulfate intravenously . Am . Heart J., 24 : 272, 1942 . 20 . MCMILLAN . T . M . and Ber .rsT . S . Ventricular paroxysmal tachycardia : Report of a case in a pregnant girl of sixteen years with an apparently normal heart . Am . Heart J ., 7 : 70, 1931 . 21 . LEONARD, W . A ., JR . The use of diphenylhydantoin (Dilantin) sodium in the treatment of ventricular tachycardia . Arch . Int . Med. . 101 : 714, 1958 . 22 . McGEE, R . R . and TULLIS, I . F . Ventricular tachycardia with particular consideration of digitalis therapy. Am . J. Cardiod, 3 : 300, 1959 .

THE AMERICAN JOURNAL OF CARDIOI OCY