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Wolff-Parkinson-White syndrome
‘7. Ashman, IS., and Hull, IS.: Essentials of Rlretru~xrdiograplly, ed. 2, New Work, 1941, The Macmillan (‘0. 8. Barker, I?. 5, Johnston, F. I>., and Wilson, F. S.: ;~wicular PiLloxvsmal Tachycardia With Alternation of Cycle Length. Anr. HEART J. 25: 799. 1943. A Morphologic Studp of the Cardiac 9. Glomset, D. J., and Glomset, A. T. A.: Conduction System in Iyngulates, Dog, and Man. Part 1: The Rinoatria1 Node, AM. HEART J. 20: 389, 1!)40. IO. MacWilliam. J. A.: Postural IXects on Hrxl,t-Hate au11 Blood Pressure. Quart. J. &per. Physiol. 23: 1, 1933. 11. Alexander, H. L., and Bauerlein, T. (‘.: Influence of Poatnne ox Partial HeartBloclf, hw. H&RT J. 11: ??3> ‘1936. 12. Rantuccl, 0.: Su due casi (11 IJIOCVO cardiaro parziale clinostatico, (!uorr P cireolae. 16: 441, 1932.
WOT,FF-PARKINROK-WHITE
MA.JOR
ROGER
W.
ROBINSOK,
KC.,
ARMY
ASD
SYNDROMIX
CAPTAIX
OF TETF: UNITF:D
WILLIAM
Ci. TM,MAGE,
KC.
STATES
T
HE electrocardiographic syndronle of a. short P-R interval with a long QRS complex in patients who are subject to attacks of paroxysmal tachycardia was first. described by Wilson, 1 in 1915. Isolated cases were then reported by Wedd2 and Hamburger.3 It was not until 1930 that Wolff, Parkinson, and White4 focused attention upon this clinical entity by reporting a series of eleven cases. They emphasized the benign nature of the condition. Since then, there ha.ve been several case reports from different parts of the world. The largest group of cases (twenty-two) was reported by Hunter, Papp, and Parkinsoq5 in 1930. They stat,ed that this syndrome constituted 5 per cent of their cases of bundle branch block, ancl was present in 5 per cent of their patients who were subject to paroxysmal tachycardia. They collected one hundred nine cases from the literature. Recently, five cases have come to our attention, two with unusual features. Three of the cases were observed in the Army. The benign naturse of the condition had not been recognized on previous examinations. The important, factor in ascertaining whether t!hese patients should 1)~ retained in the Army or returned to civilian life depends npon the ft*equeti(;~ and disability produced by the attacks of tachycardia, and not on the bizarre appearance of the elec%rocardiogram. If the attacks of tachycardia are infrequent and of short duration, and stopped promptly by vagus stimulation or abolished by yuinidine, these patients may perform useful service in the Army. The purpose of this paper is to report the cases that we have observed. CASE
REPORTS
CASE I.-This patient \vB:: a 2%yrx~olcl white man. There tory of vascular disease in his family. His father, rnothcr, and ‘I’llere was no past history of rheumatic fever, chorea, syphilis, or ‘ ‘ spinxl meningitis ’ ’ at the age of 15 years, with an uneventful plaint was of eight attacks of palpitation since F’ehruary, only a few minutes, and the onset, of each was sudden. The attacks held his lreitth or applied stimulation to the carotid sinus. The
Recrivrd
for
publication
July
l;‘,
1944.
was a strongly positive hisbrother have hypertension. hypertension. He had had recovery. His chief c.om19417. Each attack lasted stopped promptly when he parient, a physician, stated
The peripheral arteries were normal. On examination, his blood pressure was 150/110. The heart ~vas normal size. The The fundi showed no evidence of retinal insular diaensc. The heart, size was normal on roentheart rhythm was regular and no murmurs were heard. The blood and urine were normal. The ldood nonprotein nitrogen genologic examination. llis urine concenwas 35 mg. per cent, and the phenolsulfonpl~tllalein excretion, 75 pe. r cent. trated to 1.024 and diluted to 1.002. The sedimentation rate 1va.s 6l mm. (Westergren .Zn excretion pyelogrnnl was normal. and the blood Kahn reaction was negative. method), of 0.10 to 0.12 second, id it An electrocardiogram (Fig. 2) showed a short P-R interval, lorlg QRS interval, of 0.12 second. An u~~usual feature of :his case was inversion of the P waves in Lead III. The P waves are supposedly upright in all leads in this syndrome. Subsequent tracings were identical with this one. This patient was a physician. He did not have attacks of tachycardia, so that he He mad reclassifietl on a -imited iiuty status, cotiwa.s not disabled by this syndrome. fined to the continental United States heeausc of the hypertension, and not because of his electrocardiogram.
a.
b.
B?F;. B.--Case
c.
3.
IJescription
a.
in text.
Case 3.-This patient was a 29.year-old, m-bite, male ofiicer. There was no history of vascular disease in this patient’s famil?-. He had not had i,heumxtic fever, chorea, syphilis, or hypertension. His chief complaint was of recurrent att,aeks of palpitation during the preceding year. The attacks began suddenly, lasted several hours each time, and were relieved by lying down, bending over, or holding his breath. On physical examination, his blood pressure was 1 lO/(irj. The retinal vessels an:’ peripheral arteries were normal. Esamination OF the heart was negative. The urine, blood, and Kahn reaction \vere negative. The sedimentation rate rvas 2 mm. (Westcrgren method). The blood nonprotein nitrogen was ::I mg., and the sugar, iS mg., per cent. The heart size was normal on roentgonologic ex:rmin:Ltion. An electrocardiogram (Fig. 3, (8) 1 taken Oct. 30, 1!)43, showc:l auricnlar 1:1cI1~c:trdi:1., wit11 a l’ate of ISO. Pig. 3, h shows a normal tracing, with a PR interval (II’ O.Zll sccol!(l :lll~i :L QRS iuterval of 0.08 second; this was reeordctl Dee. 7, l!)-I::. Pig. 3, C’ sl10ws the cllarncteristic short P-R interval (0.09 second) and long QRS interval (0.14 second ). l’orty nrinutrs after I,+5 grain of atropine subcutaneously, the QRS interval was shortened slightly in I,ead I (Fig. 3, d). Fig. 4
a.
b. Fig.
Fig.
c.
B.-Case
7.-case
4.
5,
Description
Pwcription
in text.
in
text.
d.
TISE
PROGNOSTIC SIGNIFICANCE IN ASSOCIATION WITH
OF A1JRICUT~AR P’IBRIIJIIATION MYOCARI~IAL INF.~RCTTON
A
URICULAR fibrillation is infrcqucntly associntcd with myocardial infarction. PqgosticalIy, it has not been r~e~artled as a serious cornpli~;ttion alone, but rather as a reflection of an ad\anced degree of cardiac I’aifure. It has been regarded as usually transient, recluiring no specific consideration. Fecause of its infrequency, no large series of cases has been analyzed. Master, Dack, and Jaffel found 22 instances among 300 patients with myoenrdial infarction (7.3 per cent) ; Rosenbaum and Levine’ found 25 arnon~ 2OR paticnls (12 per cent), and Rathe,” 35 among 2.74 patients (12.7 peg cent). R1;tTERI.K
We have studied 84 patients with a77ricular fibt-illalion; this occurred in a group of 1,237 patients with myocnrtlial infarction whu were atltnitted to the Los Angeles County Genera.1 Hospital, an ineidencc of 7.7 peg c:cnt. This paper concerns itself only with the prognostic significance of l-he :~~~hylh~r~ia in these casts. The diagnosis of myocnrclial inCnr&on wvc”s acctptctl only when the history and eJectroeal,cliograll~ were t.ypical. Auricular fil)rillntion w:w diagnosed only when confirmed by elee~roc~;lrtliogl,nms. h-h~h~ji Jllnlly CZLSCS of transient fibrillation, with no tracings, were o~e~~looke~l. Therefore, the figures do not actually represent the iaridence of the auhythn~i;i in its transient form. They should, however, ~epresc~nt I-he incidence of the persistent form in this group. Contrary to expectations, au:.icnlar fibrillation was found to bc persistent in a large number of cases. 1.1129 instilnc~es tile awhythniia disap pcared ; in 55 it persisted. MORT,kLITY
RATES
The mortality among the 1,247 patients with ~u.vocardiaI infarction daring their hospitalization (about one month) KRS 642, R mte of 51..5 per cent (Table I). The 84 patients with auricular fibrillation 11a.d a definitely higher death rate. In the 29 eases in which the al*rhythntia disappeared, the mortal.ity rate and
From thr Depnrtrncnt the Los Angeles County Keceivea for publ,ication
Medicine, IJnivet’sity General Hospital. July X6, 1944.
of
of
Southern
Caiifomia
School
of
Medicine,
WOT,FF-PARKINROK-WHITE
MA.JOR
ROGER
W.
ROBINSOK,
KC.,
ARMY
ASD
SYNDROMIX
CAPTAIX
OF TETF: UNITF:D
WILLIAM
Ci. TM,MAGE,
KC.
STATES
T
HE electrocardiographic syndronle of a. short P-R interval with a long QRS complex in patients who are subject to attacks of paroxysmal tachycardia was first. described by Wilson, 1 in 1915. Isolated cases were then reported by Wedd2 and Hamburger.3 It was not until 1930 that Wolff, Parkinson, and White4 focused attention upon this clinical entity by reporting a series of eleven cases. They emphasized the benign nature of the condition. Since then, there ha.ve been several case reports from different parts of the world. The largest group of cases (twenty-two) was reported by Hunter, Papp, and Parkinsoq5 in 1930. They stat,ed that this syndrome constituted 5 per cent of their cases of bundle branch block, ancl was present in 5 per cent of their patients who were subject to paroxysmal tachycardia. They collected one hundred nine cases from the literature. Recently, five cases have come to our attention, two with unusual features. Three of the cases were observed in the Army. The benign naturse of the condition had not been recognized on previous examinations. The important, factor in ascertaining whether t!hese patients should 1)~ retained in the Army or returned to civilian life depends npon the ft*equeti(;~ and disability produced by the attacks of tachycardia, and not on the bizarre appearance of the elec%rocardiogram. If the attacks of tachycardia are infrequent and of short duration, and stopped promptly by vagus stimulation or abolished by yuinidine, these patients may perform useful service in the Army. The purpose of this paper is to report the cases that we have observed. CASE
REPORTS
CASE I.-This patient \vB:: a 2%yrx~olcl white man. There tory of vascular disease in his family. His father, rnothcr, and ‘I’llere was no past history of rheumatic fever, chorea, syphilis, or ‘ ‘ spinxl meningitis ’ ’ at the age of 15 years, with an uneventful plaint was of eight attacks of palpitation since F’ehruary, only a few minutes, and the onset, of each was sudden. The attacks held his lreitth or applied stimulation to the carotid sinus. The
Recrivrd
for
publication
July
l;‘,
1944.
was a strongly positive hisbrother have hypertension. hypertension. He had had recovery. His chief c.om19417. Each attack lasted stopped promptly when he parient, a physician, stated
The peripheral arteries were normal. On examination, his blood pressure was 150/110. The heart ~vas normal size. The The fundi showed no evidence of retinal insular diaensc. The heart, size was normal on roentheart rhythm was regular and no murmurs were heard. The blood and urine were normal. The ldood nonprotein nitrogen genologic examination. llis urine concenwas 35 mg. per cent, and the phenolsulfonpl~tllalein excretion, 75 pe. r cent. trated to 1.024 and diluted to 1.002. The sedimentation rate 1va.s 6l mm. (Westergren .Zn excretion pyelogrnnl was normal. and the blood Kahn reaction was negative. method), of 0.10 to 0.12 second, id it An electrocardiogram (Fig. 2) showed a short P-R interval, lorlg QRS interval, of 0.12 second. An u~~usual feature of :his case was inversion of the P waves in Lead III. The P waves are supposedly upright in all leads in this syndrome. Subsequent tracings were identical with this one. This patient was a physician. He did not have attacks of tachycardia, so that he He mad reclassifietl on a -imited iiuty status, cotiwa.s not disabled by this syndrome. fined to the continental United States heeausc of the hypertension, and not because of his electrocardiogram.
a.
b.
B?F;. B.--Case
c.
3.
IJescription
a.
in text.
Case 3.-This patient was a 29.year-old, m-bite, male ofiicer. There was no history of vascular disease in this patient’s famil?-. He had not had i,heumxtic fever, chorea, syphilis, or hypertension. His chief complaint was of recurrent att,aeks of palpitation during the preceding year. The attacks began suddenly, lasted several hours each time, and were relieved by lying down, bending over, or holding his breath. On physical examination, his blood pressure was 1 lO/(irj. The retinal vessels an:’ peripheral arteries were normal. Esamination OF the heart was negative. The urine, blood, and Kahn reaction \vere negative. The sedimentation rate rvas 2 mm. (Westcrgren method). The blood nonprotein nitrogen was ::I mg., and the sugar, iS mg., per cent. The heart size was normal on roentgonologic ex:rmin:Ltion. An electrocardiogram (Fig. 3, (8) 1 taken Oct. 30, 1!)43, showc:l auricnlar 1:1cI1~c:trdi:1., wit11 a l’ate of ISO. Pig. 3, h shows a normal tracing, with a PR interval (II’ O.Zll sccol!(l :lll~i :L QRS iuterval of 0.08 second; this was reeordctl Dee. 7, l!)-I::. Pig. 3, C’ sl10ws the cllarncteristic short P-R interval (0.09 second) and long QRS interval (0.14 second ). l’orty nrinutrs after I,+5 grain of atropine subcutaneously, the QRS interval was shortened slightly in I,ead I (Fig. 3, d). Fig. 4
a.
b. Fig.
Fig.
c.
B.-Case
7.-case
4.
5,
Description
Pwcription
in text.
in
text.
d.
TISE
PROGNOSTIC SIGNIFICANCE IN ASSOCIATION WITH
OF A1JRICUT~AR P’IBRIIJIIATION MYOCARI~IAL INF.~RCTTON
A
URICULAR fibrillation is infrcqucntly associntcd with myocardial infarction. PqgosticalIy, it has not been r~e~artled as a serious cornpli~;ttion alone, but rather as a reflection of an ad\anced degree of cardiac I’aifure. It has been regarded as usually transient, recluiring no specific consideration. Fecause of its infrequency, no large series of cases has been analyzed. Master, Dack, and Jaffel found 22 instances among 300 patients with myoenrdial infarction (7.3 per cent) ; Rosenbaum and Levine’ found 25 arnon~ 2OR paticnls (12 per cent), and Rathe,” 35 among 2.74 patients (12.7 peg cent). R1;tTERI.K
We have studied 84 patients with a77ricular fibt-illalion; this occurred in a group of 1,237 patients with myocnrtlial infarction whu were atltnitted to the Los Angeles County Genera.1 Hospital, an ineidencc of 7.7 peg c:cnt. This paper concerns itself only with the prognostic significance of l-he :~~~hylh~r~ia in these casts. The diagnosis of myocnrclial inCnr&on wvc”s acctptctl only when the history and eJectroeal,cliograll~ were t.ypical. Auricular fil)rillntion w:w diagnosed only when confirmed by elee~roc~;lrtliogl,nms. h-h~h~ji Jllnlly CZLSCS of transient fibrillation, with no tracings, were o~e~~looke~l. Therefore, the figures do not actually represent the iaridence of the auhythn~i;i in its transient form. They should, however, ~epresc~nt I-he incidence of the persistent form in this group. Contrary to expectations, au:.icnlar fibrillation was found to bc persistent in a large number of cases. 1.1129 instilnc~es tile awhythniia disap pcared ; in 55 it persisted. MORT,kLITY
RATES
The mortality among the 1,247 patients with ~u.vocardiaI infarction daring their hospitalization (about one month) KRS 642, R mte of 51..5 per cent (Table I). The 84 patients with auricular fibrillation 11a.d a definitely higher death rate. In the 29 eases in which the al*rhythntia disappeared, the mortal.ity rate and
From thr Depnrtrncnt the Los Angeles County Keceivea for publ,ication
Medicine, IJnivet’sity General Hospital. July X6, 1944.
of
of
Southern
Caiifomia
School
of
Medicine,