Atrial Flutter With Complete Heart Block

The association of atrial flutter and complete heart block is very uncommon.Amongst 168 cases of atrial flutter described by Willius (1927) only one had complete heart block, and in a review of 20,000 electrocardiograms Di Gregorio and Crawford (1939) found the combined dys- rhythmia only twice.Campbell (1944) in his analysis of 64 cases of heart block does not mention the association, and of the large series of 251 patients with complete heart block discussed by Penton et al. ( 1956) four had atrial flutter.In a recent review, Korst and Wasserburger (1954) mentioned 72 cases of whom 57 were men: the ages ranged from 14 to 84 years and the great majority occurred in the sixth and later decades.We have found reports of only 14 cases under fifty, 9 men and 5 women, and of these 10 showed evidence of organic heart disease.The four cases forming the subject of this report are men under fifty years of age, and the third and fourth have no evidence of organic heart disease.Case I first came under observation in 1951 at the age of 41 complaining of stabbing pain in the right side of the chest, and had been aware of the slow pulse rate for two years.The past and family histories gave nothing unusual.The chest X-ray showed a normal heart shadow and the cardiogram revealed atrial sinus rhythm, complete heart block, and normal QRS-T complexes.In 1957 he was admitted to hospital with severe vertigo, vomiting, and paraesthesiae down the left half of the body due to thrombosis of the right posterior inferior cerebellar artery.He also described central chest pain on effort, rapidly relieved by rest, and present for the previous five years.The blood pressure was 160/90, the pulse rate was 40 a minute, and the heart was clinically normal.Cardiography (Fig. IA) showed that the atrial rate was 340 a minute and the ventricular rate 35 a minute with complete dissociation, and there was also right bundle-branch block.This appearance remained unaltered in subsequent tracings.Case 2 presented in March, 1950, at the age of 44; six months previously he had experienced sudden tightness in the chest associated with sub-sternal pain, and from that time he had noticed increasing dyspncea and sub-sternal discomfort on effort.He was found to have a pulse rate of 48 and his cardiogram (Fig. IB) showed an atrial rate of 250 a minute, a ventricular rate of 54 and right bundle-branch block.Serial records have shown a similar rhythm with some variation in atrial and ventricular rates, and apart from one brief period of atrial sinus rhythm the flutter has now been present for eight years.The QRS-T complexes have varied considerably, associated with episodes of prolonged sub-sternal pain and some illustrative tracings are shown in Fig. 2.Congestive heart failure developed in 1954 and has since recurred several times, paracentesis abdominis being required in 1954, 1957, and 1958.Since failure first occurred the predominant symptoms have been dyspncea and lassitude and there has been little pain.Stokes-Adams attacks have been present in recent months only.Serial radiographs have shown progressive cardiac enlargement (cardio-thoracic ratio, 50% in 1950, 57% in 1953, 65% in 1955, and 69% in 1958).Case 3, a moulder, aged 32, was seen in 1955 having had transient dizziness on two occasions during the previous eighteen months, each attack lasting for a few minutes.There was no significant past or family history.The blood pressure was 140/80, he had a regular pulse rate of 40 a minute, the heart was not enlarged, the heart sounds were normal, and there was a soft systolic ejection murmur in the third left inter- costal space attributed to the bradycardia.