I ,..II "Of • ~ ., _" "m':: .;t.. ~ ~ ~ s < ~ )! A .J. .NCth;~ 1.;...;... J CLIMICAL CARDIOLOGY ~~ CLINICAL ASPECTS OF CARDIAC ARRHYTHMIAS ~ @lIIJ " 00,0; "(IG CLINICAL CARDIOLOGY CLINICAL ASPECTS OF CARDIAC ARRHYTHMIAS Edited by A. John Camm Department of Cardiological Sciences St. George's Hospital Medical School Cranmer Terrace London and David E. Ward St. George's Hospital Blackshaw Road London KLUWER ACADEMIC PUBLISHERS DORDRECHT-BOSTON-LONDON Distributors for the United States and Canada: Kluwer Academic Publishers, PO Box 358, Accord Station, Hingham, MA 02018-{)358, USA for all other countries: Kluwer Academic Publishers Group, Distribution Center, PO Box 322, 3300 AH Dordrecht, The Netherlands British Library Cataloguing in Publication Data Clinical aspects of cardiac arrhythmias. 1. Man. Heart. Arrhythmia I. Camm, A. John II. Ward, David E. III. Series 616.1'28 Library of Congress Cataloging-in-Publication Data Clinical aspects of cardiac arrhythmias. (Current status of clinical cardiology) Includes bibliographies and index. 1. Arrhythmia. I. Camm, A. John. II. Ward, David E. III. Series. [DNLM: 1. Arrhythmia-physiopathology. 2. Electrocardiography. 3. Electrophysiology. WG 330 C6405] RC685.A65C541988 616.1'28 88-12801 JSBN-13:978-94-010-7073-7 e-JSBN-13:978-94-009-1289-2 001: I 0.1 007/978-94-009-1289-2 Copyright © 1988 by Kluwer Academic Publishers Softcover reprint of the hardcover 1s t edition 1988 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission from the publishers, Kluwer Academic Publishers BY, PO Box 17,3300 AA Dordrecht, The Netherlands. Published in the United Kingdom by Kluwer Academic Publishers, PO Box 55, Lancaster, UK. Kluwer Academic Publishers BY incorporates the publishing programmes of D. Reidel, Martinus Nijhoff, Dr W. Junk and MTP Press. Contents Preface Xl Series Editor's Note X1 11 List of Contributors xv 1 Mechanisms of tachycardia in the experimental setting 1 and their possible clinical importance S.M. Cobbe 2 Metabolic factors in the genesis of ventricular arrhyth- 15 mlas D. C. Russell 3 The electrophysiology of reperfusion-induced arrhyth- 33 mias following acute myocardial ischaemia N. A. Flores and D.]. Sheridan 4 Autonomic tone modulation of cardiac arrhythmias 49 C. S. Butrous 5 Haemodynamic consequences of cardiac arrhythmias 59 C. Kaye and A.J. Camm 6 The morphological correlates of atrial and ventricular 77 tachycardias M.J. Davies 7 Diagnosis of cardiac arrhythmias from the surface elec- 95 trocardiogram D. W. Davies and W. D. Toff v CONTENTS 8 Ambulatory electrocardiographic monitoring the 119 In diagnosis of arrhythmias A.K. Brown 9 The role of electrophysiological study in the diagnosis 137 of arrhythmias E. Rowland 10 Signal-averaged surface electrocardiography 163 R. Vincent 11 Arrhythmias in children 179 ]. A. Till and D. E. Ward 12 Special aspects of arrhythmias in the elderly 201 A. Martin 13 Normal and abnormal responses of cardiac rhythm to 211 spontaneous physiological manoeuvres D. Mehta, D.E. Ward and A.]. Camm 14 Ventricular arrhythmias in acute myocardial infarction 237 R. W. F. Campbell 15 Practical cardiac pacing 247 E.]. Perrins 16 External electrical defibrillation and cardioversion 263 ]. C. P. Crick 17 Drugs used for the treatment of tachycardias 285 R. S. Bexton 18 The arrhythmogenic effects of antiarrhythmic drugs. 301 Types, mechanisms and predisposing factors c.]. Garratt and A.]. Camm 19 Digitalis and arrhythmias 311 R. Hayward vi CONTENTS 20 Implantable electrical devices for the treatment of tachy- 337 arrhythmias D. B. O'Keef{e 21 The high energy catheter ablation technique in the man- 359 agement of tachyarrhythmias P. Holt and E. Boyd 22 Surgery for the treatment of tachycardias 375 A. W. Nathan 23 Cardiopulmonary resuscitation 403 D. A. Zideman Index 415 vii Current Status of Clinical Cardiology Series Drugs in the Management of Heart Disease Edited by A. Breckenridge Heart Muscle Disease Edited by f. F. Goodwin Congenital Heart Disease Edited by F. J. Macartney Ischaemic Heart Disease Edited by K. M. Fox Immunology and Molecular Biology of Cardiovascular Diseases Edited by C. f. F. Spry Clinical Aspects of Cardiac Arrhythmias Edited by A. f. Camm and D. E. Ward ix Preface We were particularly pleased to compile this volume entitled 'Clinical Aspects of Cardiac Arrhythmias'. Recent years have seen the publication of many textbooks on cardiac arrhythmias, some of which concentrate on one particular aspect such as drug management, electrocardiographic appearances, electrophysiological evaluation etc; and others of which are the collated reports of symposia, often dealing with detailed con siderations of highly specialised problems. Most of the larger more comprehensive texts have devoted a substantial proportion to basic considerations and experimental observations, far removed from the clinical arena. When asked to contribute to the series 'Current Status of Clinical Cardiology' we felt that the clinical aspects of cardiac arrhyth mias should be emphasized, and that the text should be as comprehensive as possible within the limitations of a single volume in this series. This comprehensive but clinical approach has necessitated the inclusion of certain subjects such as the mechanisms of tachycardia, metabolic aspects of cardiac arrhythmias and reperfusion arrhythmias, which are not directly or exclusively clinical. However, the rapid advances in these areas in recent years are likely to have increasingly important clinical con seq uences. Although the epidemiology of clinical arrhythmias is difficult to dis cover, it is widely appreciated that arrhythmias are commonplace. For example, the Wolff-Parkinson-White pattern is found in one in 500 live births, sudden unexpected cardiac death occurs in approximately one per 1000 of the population each year; atrial fibrillation is the predominant rhythm in 10% of the elderly population, and about 1 % of the total population has significant paroxysmal supraventricular tachycardia. The high prevalence of disabling or life threatening arrhythmias has encouraged the development of many sophisticated techniques for their investigation. Each year many new anti-arrhythmic drugs, implantable devices and anti-arrhythmic ablative procedures are introduced and described. The investigation and treatment of cardiac arrhythmias have spawned an enormous literature which constitutes one of the largest in cardiological xi PREFACE journals. Those concerned with the management of cardiac arrhythmias are, therefore, faced with an almost impossible task of keeping up to date. We, therefore, asked the twenty-eight contributors, each working in the United Kingdom, to provide current and comprehensive reviews. In this multi-authored text we have tried to maintain consistent pres entation, whilst preserving the individual approach. Although written predominantly for physicians, we hope that this book will interest all those involved in the care of patients with cardiac arrhythmias. A. John Camm David E. Ward London 1988 xii Series Editor's Note The last few decades have seen an explosion in our knowledge of cardiovascular disease as a result of research in many disciplines. The tempo of research is ever increasing, so that it is becoming more and more difficult for one person to encompass the whole spectrum of the advances taking place on many fronts. Even more difficult is to include the advances as they affect clinical practice in one textbook of cardiovascular disease. Fifty years ago all that was known about cardiology could be included in one textbook of moderate size and at that time there was little research so that a textbook remained up to date for several years. Today all this has changed, and books have to be updated at frequent intervals to keep up with the results of research and changing fashions. The present series has been designed to cover the field of cardio vascular medicine in a series of, initially, eight volumes which can be updated at regular intervals and at the same time give a sound basis of practice for doctors looking after patients. The volumes include the following subjects: heart muscle disease; congenital heart disease, invasive and non-invasive diagnosis; ischaemic heart disease; immunology and molecular biology of the heart in health and disease; irregularities of the heart beat; and each is edited by a distinguished British author with an international reputation, together with an international panel of contributors. The series will be mainly designed for the consultant cardiologist as reference books to assist him in his day-to-day practice and keep him up to date in the various fields of cardiovascular medicine at the same time as being of manageable size. ]. P. Shillingford British Heart Foundation xiii