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Retrograde Wenckebach phenomenon in ventricular tachycardia
Letters
to the Editor
Menstruation
and heart
disease
To The Editor: I was intrigued by Seely’s editorial (March, 1976 issue’) which suggests that menstruation may play a role in protecting women against heart disease-surely one of the few beneficial things that have been written about menstruation in the course of medical history and appropriate to current feminist concepts. He then alludes to a possible beneficial role of venesection, that mainstay of medieval medicine. One of the ways to check this theory would be to look at cardiovascular mortality rates in blood donors, and I would be interested to know if anyone has any information on this. Demonstration of a beneficial effect of blood donation would be a welcome aid to sorely-pressed blood banks around the world. Michael Goodyear Department of Haematology Prince Henry’s Hospital St. Kilda Road Melbourne, 3004 Australia REFERENCE
1. Seely, S.: Possible reasons for the comparatively high resistance of women to heart disease, AM. HEART J. 91275, 1976.
Blood
donors
and coronary
disease
To the Editor: In reply to Dr. Goodyear’s letter may I say, 6rst of all, that the appropriateness of my views to current feminist concepts, as well as their possible resemblance of medieval practices, are purely accidental. I have not realized that I made medical history by being the first to say a kind word about menstruation. I certainly do not know of anyone having done so in the past, but Shakespeare might have had the same idea when pointing out that every cloud had a silver lining. He did not make his meaning entirely clear, but then he used only six words as against 3,996 in my article. As far as I know, no literature is available on differences in cardiovascular mortality rates between blood donors and a suitable control group. Before I called attention to the possibility that it could be hemorrhages, not estrogens, that may have a prophylactic effect on atherogenesis, it does not seem to have occurred to anyone to carry out such a survey. After the publication of the article the possibility seems to have generated some interest. Investigation concerning mortality rates of blood donors, particularly mu& blood donors, has already been suggested twice to me in correspondence related to the article, notably by Dr. B. Moors, the University of Mancheater, and by a doctor in Hospital Cantonal Geneve, whose. name 1 could not decipher. I cannot carry out such an investigation myself, but I would be glad if someone did. There are two alternatives such a survey could
American
Heart
Journal
take. It would be possible to select a group of male blood donors, preferably in the over-forty age groups, whose future medical history would be followed. Alternatively it would be possible to select a group who were blood donors, let us say, 20 years ago, and attempt to trace their history in the intervening years. Obviously, the disadvantage of the first method is the long time it would take to obtain statistically significant results, and of the second the great difficulties and expense involved in tracing the fate of the selected groups. A considerable amount of research has been done on the allied subject of differential resistivity of women with early and late onset of menopause, the early onset being due either to natural causes or ovaryectomy. A recent leading article in the British Medical Journal’ gave a somewhat sketchy survey of the past literature dealing with the subject, as well as some editorial opinions, the latter hotly debated in subsequent editorial correspondence.2~ 3 The most interesting of the quoted references is a Swedish study’ comparing the menstrual histories of women with known coronary heart disease with a randomly selected control group. According to this, 76 per cent of the women admitted to hospital with myocardial infarction had passed through the menopause before the age of 59, in comparison with 48 per cent of the controls. In women, however, the cessation of menstrual hemorrhages is inseparable from hormonal changes, so that it is impossible to know with certainty which one of these factors affects resistivity to coronary heart disease. This is the reason why an investigation on male blood donors would be important. I might, perhaps, add that I wrote two subsequent papers to the article under consideration. One5 is published in the November, 1977, issue of Medical Hypotheses, the other on “The atherogenic effect of stilbestrol” was recently submitted to AMERICANHEARTJOURNAL. Stephen Seely B.Sc. 3 Truro Drive Sale, Cheshire, M33 5DF England REFERENCES
1. Leading article: Coronary heart disease and the menopause, Br. Med. J. 13362, 1977. 2. Elkeles, A.: Letter to the Editor (in answer to article of Ref. l), Br. Med. J. 1:1215, 1977. 3. Bye, P.: Letter to the Editor (in answer to article of Ref. l), Br. Med. J. 1:1215, 1977. 4. Bengtason, C.: Ischaemic heart disease in women, Acta Med. Stand. Suppl. 549, 1977. 5. Seely, S.: Surfactants and atherogenesis, Med. Hypotheses 3:259, 1977.
Overdiagnosis
of left anterior
hemiblock
To the Editor: In the October, 1977, issue of THIS JOURNAL Dr. G. E. Burch cautions against overdiagnosing left anterior hemiblock &AH). This caution is justified, but Rosenbaum, in his
675
Letters
to the Editor
monograph, discussed the differences between this form of fascicular block and horizontal heart with clockwise rotation, LVH, etc. His criteria included an axis of -60 degrees-but at least -45 degrees. In Dr. Burch’s example the axis is not that far to the left. Other possibilities of incorrectly diagnosing LAH include inferior infarction with large Q waves, aberrant conduction due to pre-excitation, and others. In the case of LVH the question still has to be solved if an axis of -60 degrees in LVH could not be due to fascicular Mock, caused perhaps by stretching of the septal fibers. Of course, the diagnosis of LAH per se does not imply a grave prognosis and in an asymptomatic patient a pacemaker is certainly not indicated.
Otto Neurath, M.D. Professor of Medicine New Jersey Medical School New Jersey College of Medicine and Dentistry Newark, New Jersey
Retrograde Wenckebach in ventricular tachycardia
right atrium show a retrograde ventriculoatrial conduction with a progressive prolongation of the ventriculoatrial interval, followed by a nonconducted ventricular beat, thus a retrograde Wenckebach phenomenon, as shown on the two IC electrograms recorded simultaneously.“, ’
S.Cotoi CGeorgescu P.Cozlea First Medical Clinic (Dir.Prof.dr.C.Dudea) Institut Medico-Farm. 4300-Tirgu-Mures Roman& REFERENCES
1. Goldreyer, 2. 3.
phenomenon 4.
To the Editor: The purpose of this letter is to present a rather rare ventriculoatrial conduction during ventricular tachycardia, documented by intracavitary (IC) recordings.‘-” In a 69-year-old man with resistant ventricular tachycardia, antiarrhythmic drugs and four electric shocks had been without result. Therefore, a tripolar electrode catheter was inserted into the right heart,’ and short periods of ventricular overdriving succeeded in converting the heart to sinus rhythm.5 The IC electrograms recorded during arrhythmia from the
Fig. 1. A simultaneous panel is a diagrammatic activity.
676
recording of three intracavitary presentation. Paper speed,
5.
6.
7.
electrograms 50 mm. per
B. N., and Bigger, J. T.: Ventriculo-atria1 conduction in man, Circulation 41:936,1979. Kistin, A. D.: Retrograde conduction to the atria in ventricular tachycardia, Circulation 24236, 1961, Nicolai, P., Delaage, M., Medvedovschi, L., Amoux, M., and Jouve, A.: Conduction auriculaire retrograde permanente en court de tachycardie ventriculaire, Arch. Mal. Coeur 63:1057, 1970. Cotoi, S., and Dragulescu, S.: A simple intracavitary bedside method for estimation of the P-R interval, Cor vaea 1796, 1975. Waldo A. L., Kongrad, E., Kupersmith, J., Levine, 0. R., Bowman, F. O., and Hoffman, B. F.: Ventricular paired pacing to control rapid ventricular heart rate following open heart surgery, Circulation 53:176, 1976. Damato, A. N., Lau, S. H., and Bobb, G. A.: Studies on ventriculo-atria1 conduction and the re-entry phenomenon, Circulation 41~423, 1970. Puech, P., Grolleau, R., Latour, H., Cabasson, J., and Marin, J.: Diagnostic des tachycardies ventriculaires avec conduction r4trograde par la stimulation endocavitaire, Arch. Mal. Coeur 84:789, 1971.
from the right atrium (ICRA). In the bottom second. A = Atria1 activity; V = ventricular
May, 1978, Vol. 95, No. 5
to the Editor
Menstruation
and heart
disease
To The Editor: I was intrigued by Seely’s editorial (March, 1976 issue’) which suggests that menstruation may play a role in protecting women against heart disease-surely one of the few beneficial things that have been written about menstruation in the course of medical history and appropriate to current feminist concepts. He then alludes to a possible beneficial role of venesection, that mainstay of medieval medicine. One of the ways to check this theory would be to look at cardiovascular mortality rates in blood donors, and I would be interested to know if anyone has any information on this. Demonstration of a beneficial effect of blood donation would be a welcome aid to sorely-pressed blood banks around the world. Michael Goodyear Department of Haematology Prince Henry’s Hospital St. Kilda Road Melbourne, 3004 Australia REFERENCE
1. Seely, S.: Possible reasons for the comparatively high resistance of women to heart disease, AM. HEART J. 91275, 1976.
Blood
donors
and coronary
disease
To the Editor: In reply to Dr. Goodyear’s letter may I say, 6rst of all, that the appropriateness of my views to current feminist concepts, as well as their possible resemblance of medieval practices, are purely accidental. I have not realized that I made medical history by being the first to say a kind word about menstruation. I certainly do not know of anyone having done so in the past, but Shakespeare might have had the same idea when pointing out that every cloud had a silver lining. He did not make his meaning entirely clear, but then he used only six words as against 3,996 in my article. As far as I know, no literature is available on differences in cardiovascular mortality rates between blood donors and a suitable control group. Before I called attention to the possibility that it could be hemorrhages, not estrogens, that may have a prophylactic effect on atherogenesis, it does not seem to have occurred to anyone to carry out such a survey. After the publication of the article the possibility seems to have generated some interest. Investigation concerning mortality rates of blood donors, particularly mu& blood donors, has already been suggested twice to me in correspondence related to the article, notably by Dr. B. Moors, the University of Mancheater, and by a doctor in Hospital Cantonal Geneve, whose. name 1 could not decipher. I cannot carry out such an investigation myself, but I would be glad if someone did. There are two alternatives such a survey could
American
Heart
Journal
take. It would be possible to select a group of male blood donors, preferably in the over-forty age groups, whose future medical history would be followed. Alternatively it would be possible to select a group who were blood donors, let us say, 20 years ago, and attempt to trace their history in the intervening years. Obviously, the disadvantage of the first method is the long time it would take to obtain statistically significant results, and of the second the great difficulties and expense involved in tracing the fate of the selected groups. A considerable amount of research has been done on the allied subject of differential resistivity of women with early and late onset of menopause, the early onset being due either to natural causes or ovaryectomy. A recent leading article in the British Medical Journal’ gave a somewhat sketchy survey of the past literature dealing with the subject, as well as some editorial opinions, the latter hotly debated in subsequent editorial correspondence.2~ 3 The most interesting of the quoted references is a Swedish study’ comparing the menstrual histories of women with known coronary heart disease with a randomly selected control group. According to this, 76 per cent of the women admitted to hospital with myocardial infarction had passed through the menopause before the age of 59, in comparison with 48 per cent of the controls. In women, however, the cessation of menstrual hemorrhages is inseparable from hormonal changes, so that it is impossible to know with certainty which one of these factors affects resistivity to coronary heart disease. This is the reason why an investigation on male blood donors would be important. I might, perhaps, add that I wrote two subsequent papers to the article under consideration. One5 is published in the November, 1977, issue of Medical Hypotheses, the other on “The atherogenic effect of stilbestrol” was recently submitted to AMERICANHEARTJOURNAL. Stephen Seely B.Sc. 3 Truro Drive Sale, Cheshire, M33 5DF England REFERENCES
1. Leading article: Coronary heart disease and the menopause, Br. Med. J. 13362, 1977. 2. Elkeles, A.: Letter to the Editor (in answer to article of Ref. l), Br. Med. J. 1:1215, 1977. 3. Bye, P.: Letter to the Editor (in answer to article of Ref. l), Br. Med. J. 1:1215, 1977. 4. Bengtason, C.: Ischaemic heart disease in women, Acta Med. Stand. Suppl. 549, 1977. 5. Seely, S.: Surfactants and atherogenesis, Med. Hypotheses 3:259, 1977.
Overdiagnosis
of left anterior
hemiblock
To the Editor: In the October, 1977, issue of THIS JOURNAL Dr. G. E. Burch cautions against overdiagnosing left anterior hemiblock &AH). This caution is justified, but Rosenbaum, in his
675
Letters
to the Editor
monograph, discussed the differences between this form of fascicular block and horizontal heart with clockwise rotation, LVH, etc. His criteria included an axis of -60 degrees-but at least -45 degrees. In Dr. Burch’s example the axis is not that far to the left. Other possibilities of incorrectly diagnosing LAH include inferior infarction with large Q waves, aberrant conduction due to pre-excitation, and others. In the case of LVH the question still has to be solved if an axis of -60 degrees in LVH could not be due to fascicular Mock, caused perhaps by stretching of the septal fibers. Of course, the diagnosis of LAH per se does not imply a grave prognosis and in an asymptomatic patient a pacemaker is certainly not indicated.
Otto Neurath, M.D. Professor of Medicine New Jersey Medical School New Jersey College of Medicine and Dentistry Newark, New Jersey
Retrograde Wenckebach in ventricular tachycardia
right atrium show a retrograde ventriculoatrial conduction with a progressive prolongation of the ventriculoatrial interval, followed by a nonconducted ventricular beat, thus a retrograde Wenckebach phenomenon, as shown on the two IC electrograms recorded simultaneously.“, ’
S.Cotoi CGeorgescu P.Cozlea First Medical Clinic (Dir.Prof.dr.C.Dudea) Institut Medico-Farm. 4300-Tirgu-Mures Roman& REFERENCES
1. Goldreyer, 2. 3.
phenomenon 4.
To the Editor: The purpose of this letter is to present a rather rare ventriculoatrial conduction during ventricular tachycardia, documented by intracavitary (IC) recordings.‘-” In a 69-year-old man with resistant ventricular tachycardia, antiarrhythmic drugs and four electric shocks had been without result. Therefore, a tripolar electrode catheter was inserted into the right heart,’ and short periods of ventricular overdriving succeeded in converting the heart to sinus rhythm.5 The IC electrograms recorded during arrhythmia from the
Fig. 1. A simultaneous panel is a diagrammatic activity.
676
recording of three intracavitary presentation. Paper speed,
5.
6.
7.
electrograms 50 mm. per
B. N., and Bigger, J. T.: Ventriculo-atria1 conduction in man, Circulation 41:936,1979. Kistin, A. D.: Retrograde conduction to the atria in ventricular tachycardia, Circulation 24236, 1961, Nicolai, P., Delaage, M., Medvedovschi, L., Amoux, M., and Jouve, A.: Conduction auriculaire retrograde permanente en court de tachycardie ventriculaire, Arch. Mal. Coeur 63:1057, 1970. Cotoi, S., and Dragulescu, S.: A simple intracavitary bedside method for estimation of the P-R interval, Cor vaea 1796, 1975. Waldo A. L., Kongrad, E., Kupersmith, J., Levine, 0. R., Bowman, F. O., and Hoffman, B. F.: Ventricular paired pacing to control rapid ventricular heart rate following open heart surgery, Circulation 53:176, 1976. Damato, A. N., Lau, S. H., and Bobb, G. A.: Studies on ventriculo-atria1 conduction and the re-entry phenomenon, Circulation 41~423, 1970. Puech, P., Grolleau, R., Latour, H., Cabasson, J., and Marin, J.: Diagnostic des tachycardies ventriculaires avec conduction r4trograde par la stimulation endocavitaire, Arch. Mal. Coeur 84:789, 1971.
from the right atrium (ICRA). In the bottom second. A = Atria1 activity; V = ventricular
May, 1978, Vol. 95, No. 5