Paroxysmal Atrial Tachycardia with Atrioventricular Block Its Frequent Association with Chronic Pulmonary Disease By LEONARD M. GOLDBERG, M.D.. J. DAVID BRISTOW, M.D., BRENT M. PARKER, M.D., AND LEONARD W. RITZMANN, M.D. PAROXYSMAL atrial tachyeardia with atrioventricular block (PAT with block) has been recognized more often in recent years since Lown and Levine clarified its diagnostic criteria and emphasized its important relation to digitalis excess.1' 2 The present report was prompted by the increasing frequency with which this diagnosis has been made at our hospital and its common association with chronic pulmonary disease. Methods and Materials The electrocardiographic files at the Portland, Oregon, Veterans Administration Hospital were reviewed for records demonstrating PAT with block. The 5-year period from January 1954 to April 1959 was covered. In those cases found, the clinical, laboratory, and autopsy data were abstracted from the hospital charts. Emphasis was placed upon the type of heart disease present, details of digitalis and diuretic therapy, treatment and course of the arrhythmia, and outcome of the basic disease process. The electrocardiograms were analyzed for details of the arrhythmia, including atrial and ventricular rates, configuration of the atrial complexes, types of A-V block, and asso- ciated rhythm disturbances. The diagnosis of PAT with block was made solely on the basis of the electrocardiogram (fig. 1). We utilized the criteria of Lown and Le- vine, 2 which include atrial rates of 150 to 250 per minute; varying degrees of atrioventricular block (usually 2:1, Wenekebach, or varying in type) ; P waves that are upright in leads II, III, and aVF, and altered in configuration from those preceding development of the arrhythmia; an iso- electric baseline between the P waves and a P-P interval that may be slightly irregular. The de- gree of A-V block may be increased by carotid From the Veterans Administration Hospital aild the University of Oregon Medical School, Portland, Ore. massage or decreased by atropine or exercise. Ven- tricular premature contractions may be present. Sinee quinidine may slow the atrial rate of atrial flutter to below 250, we did not include cases in which quinidine had been given prior to develop- ment of the arrhythmiiia. Results The diagnosis of PAT with block was estab- lished in 37 cases. The patients ranged in age from 33 to 89. Although only 1 patient was female, this sex distribution is consistent with the total population of our hospital. In gen- eral, the patients were seriously ill with ad- vanced heart disease. Thirty-four patients had organic heart disease with atherosclerotic, the most common type, present in over one third of the cases. Cor pulmonale was almost as fre- quent, occurring in 10 cases. In addition, there were 4 cases of hypertensive cardiovascular disease, 2 of rheumatic heart disease, and 1 ease each of myocarditis, polyarteritis, con- genital heart disease, and dystrophic heart disease (i.e., progressive muscular dystrophy). There were only 3 patients in whom no heart disease could be demonstrated. Two of these were digitalized because of atrial tachyeardia and subsequently developed PAT with block. The heart disease was accompanied by conges- tive heart failure in 33 cases. An unexpected finding was the high fre- quency of serious pulmonary disease (table 1); over one half of the patients had signifi- cant lung lesions. The most common was ad- vaneed obstructive emphysema, present in 10 patients; other types included pneumonia, pulmonary embolism, bronehogenic carcinoma, and tubereulosis. A total of 22 lung lesionis was found in 20 patients. That the pulmonary Circulation, Volume XXI, April 1960 499 by guest on July 17, 2016 http://circ.ahajournals.org/ Downloaded from