7. Hermoni Y, Engel PJ. Two-dimensional echocardiography in cardiac rupture. Am J Cardiol 1986;57:180-181. 8. Ennix CL, Ecker RR, Iverson LIG, Young JN, Harrell JE Jr, Dantes DR, May IA. Early detection and management of left ventricular free wall rupture during acute myocardial infarction. Am J Cardiol 1989;63:151-152. 9. Garcia-Fernandez MA, Moreno M, Rossi PN, Lopez-Sendon JL, Banuelos F. Echocardiographic features of hemopericardium. Am Heart J 1984;107: 1035-1036.
10. Knopf WD, Talley JD, Murphy DA. An echo-dense mass in the pericardial space as a sign of left ventricular free wall rupture during acute myocardial infarction. Am J Cardiol 1987;59:1202. Il. Nanda NC, Gramiak R. Pericardial effusion. In: Clinical Echocardiography. St. Louis: CV Mosby, 1978:268-292. 12. Martin RP, Bowden R, Filly K, Popp R. Intrapericardial abnormalities in patients with pcricardial effusion: findings in two-dimensional echocardiography. Circulation 1980;61:568-572.
Can Patients Discriminate Between Atrial Fibrillation Supraventricular Tachycardia? James W. Leitch, MB, BS, George J. Klein, MD, and Raymond he clinical diagnosis of the cause of palpitations in the absence of electrocardiographic documentation relies on the patient’s description of the symptoms. Palpitations may be described as regular or irregular and some estimate of the their rapidity may be obtained. In conjunction with other observations, including duration, onset characteristics and precipitating factors, a clinical diagnosis of arrhythmias such as paroxysmal atria1 tachycardia, atria1 fibrillation.or ectopic beats can be made. 1-3The relation between these symptoms of tachycardia and actual arrhythmias has not been subjected to systematic evaluation. This pilot study examined whether patients could reliably differentiate an irregular tachycardia (atria1 fibrillation) from regular reciprocating tachycardia during an electrophysiologic study. In addition, the use of a simple analog scale to estimate tachycardia cycle length was evaluated. All patients with the Wolff-Parkinson- White syndrome undergoing electrophysiologic study were evaluatedfor participation. Patients were excluded if sustained reciprocating tachycardia and atria1 jibrillation were not inducible and if the patient was not able to communicate adequately. The electrophysiology study was performed in the nonsedated, fasting state as previously described.” If atria1 fibrillation did not occur during routine atria1 stimulation, an attempt was made to induce it by pacing the right atrium at a cycle length of 50 to 200 ms for 1 minute. When tachycardia occurred, a 12-lead electrocardiogram was recorded simultaneously with administration of the questionnaire. The standard questionnaire was administered before induction of tachycardia and then during each episode of tachycardia. Initially, the patient was asked whether the tachycardia was regular or irregular. The patient was then asked to grade the heart rate during tachycardia on a scale from 1 to 10 where I
T
From the University of Western Ontario, London, Ontario. Dr. Leitch’s address is: University Hospital, 339 Windermere Road, London, Ontario, Canada N6A 5A5. Manuscript received April 15, 1991; revised manuscript received and accepted May 28,199l.
964
THE AMERICAN
JOURNAL
OF CARDlbLOGY
VOLUME
68
and Regular
Yee, MD
represented normal heart beat and 10 represented the maximal possible heart rate. An analog scale from 1 to 10 was fixed to the ceiling and the patient was asked to mark figuratively on this scale the tachycardia rate. To maintain single blindness, no monitor was visible to the patient and all tachycardias were described as ‘tachycardia” by laboratory personnel. The administrator of the questionnaire was not unaware of the tachycardia characteristics. Each 12-lead electrocardiogram recorded a IOsecond interval of tachycardia. For atria1 fibrillation, the mean f standard deviation of the RR intervals over this period were calculated. Continuous variables were compared with the Wilcoxon rank-sum test or unpaired t test where appropriate. The relation between tachycardia cycle length and the heart rate scale was evaluated with linear regression analysis. Frequencies were compared with the chi-square test. Continuous data are reported as mean f standard deviation. There were 23 patients (mean age 34 f 12 years). Nine patients had previously documented reciprocating tachycardia, 2 patients had previously documented atrialJibrillation, 5 patients had both documented reciprocating tachycardia and atria1 fibrillation, and 7 patients had a history of palpitations only. The tachycardia cycle length for the$rst episode of reciprocating tachycardia ranged from 250 to 400 ms (mean cycle length 326 f 34). There was no significant relation between the tachycardia cycle length and the patients grading of heart rate during tachycardia on the scale from 1 to 10 (regression equation y = 12 - 0.02x, r = 0.28, p = 0.19). In 17 patients a second episode of tachycardia was induced. With the second tachycardia episode, there was again no significant relation between the tachycardia cycle length and the patient’s grading (regression equation y = I3 - 0.02x, r = 0.30, p = 0.25). When all reciprocating tachycardias were included, a weak negative relation between tachycardia cycle length and the tachycardia grade became apparent (Figure 1). Logarithmic transforOCTOBER
1, 1991
mation of the tachycardia grading did not result in substantial improvement in the relation between tachycardia grade and cycle length. To assess the reproducibility of the grading, an index for each tachycardia was determined by multiplying the tachycardia cycle length by the patient’s grading. The index for the first and second episodes of tachycardia were then compared (Figure 2). There was a strong relation between the index of the first and the second tachycardia (regression equation y = -233 + 0.8x, r = 0.81, p = 0.001).
Twenty-one of the 23 initial reciprocating tachycardia episodes were described as regular and 13 of the 17 second reciprocating tachycardia episodes were described as regular. Eleven of the 22 episodes of atrialfibrillation were described as regular (p O.l for both comparisons). Fibrilla-
y = 12 - 0.3x
I3
10 El
1
q
R = 0.33
pz.04
El
FtGURE 1. Relation between tachycardia scale and actual tachycardia cycle length in 40 episodes of induced reciprocating tachycardia. There was a weak negative relatkm between tachycarda scale and tachycardla cycle length.
300
400
tachycardia
y =
- 233
cycle
+ 0.8x
length
R = 0.81
p=.OOl
3000
FIGURE 2. Reproducibility
of techycardia scale within patids. An in&x for each tachycardll was determined by multiptying tachycarch scale by tachycardii cycte length. Thsre was a strong retation between index of the first and second tachycardia (p = 0.001).
b
2000
1000
0 1000 Index FIGURE 3. Box plot comparing the coefficient of vaffatktn (CV) in patieds with fiWlatlon eplsedes described as regular (reg) and irregular (irreg). In this plot, a* feriik denotes median value, ad beudarks of the box, the interqIartite range. . CeeffbM of variation of RR intervals was s~bdantidly higher, with fibrillatlm eplsades demfbed as irrsgubr (2 - 2.465, p = o.Ooq.
2000 for
tachycardia
3000 2
5 -I
CV(req) CV(irreg)
x X
X
BRIEF REPORTS
965
tion episodes described as irregular had a substantially higher RR interval coefficient of variation than the fibrillation episodes described as regular (23 f 7 compared with 14 f 6%, p = 0.008, Figure 3). There was no significant relation between either the mean RR or the minimal RR interval of the fibrillation episodes and the tachycardia scale.
In this study nearly all episodes of reciprocating tachycardia were described as regular. In contrast, only half the fibrillation episodes were correctly described as irregular. Therefore, the observation that sustained continuous palpitations are irregular is likely to be fairly specific but insensitive for the diagnosis of atria1 fibrillation. As might be expected, the patient’s awareness of whether a tachycardia was irregular was clearly dependent on the actual irregularity of the heart rate but not directly on the tachycardia rate itself. The irregularity of fibrillation may vary considerably depending on autonomic factors, the atria1 fibrillatory rate and properties of the atrioventricular node.5 Some episodes of fibrillation may be minimally irregular and thus mistakenly perceived as regular by the patient. A linear scale from 1 to 10 was not useful in assessing tachycardia rate because of the marked inter-patient variation. The perception of heart rate is likely to vary considerably for a number of factors. The reproducibility of this
966
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
68
scale within patients, however, was reasonable (Figure 2). Because these results were obtained in the electrophysiologic laboratory, in a select population, they may be not reproduced with spontaneous clinical arrhythmias in other patient populations. In this setting, it was not possible to evaluate other factors such as tachycardia duration, onset characteristics and precipitating events that may be helpful in the clinical diagnosis of palpitations. Nevertheless, these data suggest that a history of sustained irregular palpitations is fairly specific for atria1 fibrillation. A history of regular palpitations could be obtained with both paroxysmal atria1 tachycardia and atria1 fibrillation. 1. deLeon AC, Cheng TO. History and physical examination. In: Chew TO, ed. The International Textbook of Cardiology. New York: Pergannon Books, 1986:22-48. 2. Goldman L, Braunwald E. Cheat discomfort and palpitation. In: Wilson JD, Braunwald E, Isselbacher KJ, Petersdorf RG, Martin JB, Fauci AS, Root RK, eds. Harrison’s Principles of Medicine. New York: McGraw-Hill, 1991;98-105. 3. Braunwald E. The history. In: Braunwald E, ed. Heart Disease. A Textbook of Cardiovascular Medicine. Philadelphia: WB Saunders, 1988:1-12. 4. Leitch JW, Klein GJ, Yee R, Murdcck C. Prognostic value of electrophysiology testing in asymptomatic patients with Wolff-Parkinson-White pattern. Circulation 1990;82:1718-1723. 5. Chorro FJ, Kirchhof CJ, Brugada J, Allessie MA. Ventricular response during irregular atria1 pacing and atria1 fibrillation. Am J Physiol 1990;259:L1015H1021.
OCTOBER
1, 1991
10. Knopf WD, Talley JD, Murphy DA. An echo-dense mass in the pericardial space as a sign of left ventricular free wall rupture during acute myocardial infarction. Am J Cardiol 1987;59:1202. Il. Nanda NC, Gramiak R. Pericardial effusion. In: Clinical Echocardiography. St. Louis: CV Mosby, 1978:268-292. 12. Martin RP, Bowden R, Filly K, Popp R. Intrapericardial abnormalities in patients with pcricardial effusion: findings in two-dimensional echocardiography. Circulation 1980;61:568-572.
Can Patients Discriminate Between Atrial Fibrillation Supraventricular Tachycardia? James W. Leitch, MB, BS, George J. Klein, MD, and Raymond he clinical diagnosis of the cause of palpitations in the absence of electrocardiographic documentation relies on the patient’s description of the symptoms. Palpitations may be described as regular or irregular and some estimate of the their rapidity may be obtained. In conjunction with other observations, including duration, onset characteristics and precipitating factors, a clinical diagnosis of arrhythmias such as paroxysmal atria1 tachycardia, atria1 fibrillation.or ectopic beats can be made. 1-3The relation between these symptoms of tachycardia and actual arrhythmias has not been subjected to systematic evaluation. This pilot study examined whether patients could reliably differentiate an irregular tachycardia (atria1 fibrillation) from regular reciprocating tachycardia during an electrophysiologic study. In addition, the use of a simple analog scale to estimate tachycardia cycle length was evaluated. All patients with the Wolff-Parkinson- White syndrome undergoing electrophysiologic study were evaluatedfor participation. Patients were excluded if sustained reciprocating tachycardia and atria1 jibrillation were not inducible and if the patient was not able to communicate adequately. The electrophysiology study was performed in the nonsedated, fasting state as previously described.” If atria1 fibrillation did not occur during routine atria1 stimulation, an attempt was made to induce it by pacing the right atrium at a cycle length of 50 to 200 ms for 1 minute. When tachycardia occurred, a 12-lead electrocardiogram was recorded simultaneously with administration of the questionnaire. The standard questionnaire was administered before induction of tachycardia and then during each episode of tachycardia. Initially, the patient was asked whether the tachycardia was regular or irregular. The patient was then asked to grade the heart rate during tachycardia on a scale from 1 to 10 where I
T
From the University of Western Ontario, London, Ontario. Dr. Leitch’s address is: University Hospital, 339 Windermere Road, London, Ontario, Canada N6A 5A5. Manuscript received April 15, 1991; revised manuscript received and accepted May 28,199l.
964
THE AMERICAN
JOURNAL
OF CARDlbLOGY
VOLUME
68
and Regular
Yee, MD
represented normal heart beat and 10 represented the maximal possible heart rate. An analog scale from 1 to 10 was fixed to the ceiling and the patient was asked to mark figuratively on this scale the tachycardia rate. To maintain single blindness, no monitor was visible to the patient and all tachycardias were described as ‘tachycardia” by laboratory personnel. The administrator of the questionnaire was not unaware of the tachycardia characteristics. Each 12-lead electrocardiogram recorded a IOsecond interval of tachycardia. For atria1 fibrillation, the mean f standard deviation of the RR intervals over this period were calculated. Continuous variables were compared with the Wilcoxon rank-sum test or unpaired t test where appropriate. The relation between tachycardia cycle length and the heart rate scale was evaluated with linear regression analysis. Frequencies were compared with the chi-square test. Continuous data are reported as mean f standard deviation. There were 23 patients (mean age 34 f 12 years). Nine patients had previously documented reciprocating tachycardia, 2 patients had previously documented atrialJibrillation, 5 patients had both documented reciprocating tachycardia and atria1 fibrillation, and 7 patients had a history of palpitations only. The tachycardia cycle length for the$rst episode of reciprocating tachycardia ranged from 250 to 400 ms (mean cycle length 326 f 34). There was no significant relation between the tachycardia cycle length and the patients grading of heart rate during tachycardia on the scale from 1 to 10 (regression equation y = 12 - 0.02x, r = 0.28, p = 0.19). In 17 patients a second episode of tachycardia was induced. With the second tachycardia episode, there was again no significant relation between the tachycardia cycle length and the patient’s grading (regression equation y = I3 - 0.02x, r = 0.30, p = 0.25). When all reciprocating tachycardias were included, a weak negative relation between tachycardia cycle length and the tachycardia grade became apparent (Figure 1). Logarithmic transforOCTOBER
1, 1991
mation of the tachycardia grading did not result in substantial improvement in the relation between tachycardia grade and cycle length. To assess the reproducibility of the grading, an index for each tachycardia was determined by multiplying the tachycardia cycle length by the patient’s grading. The index for the first and second episodes of tachycardia were then compared (Figure 2). There was a strong relation between the index of the first and the second tachycardia (regression equation y = -233 + 0.8x, r = 0.81, p = 0.001).
Twenty-one of the 23 initial reciprocating tachycardia episodes were described as regular and 13 of the 17 second reciprocating tachycardia episodes were described as regular. Eleven of the 22 episodes of atrialfibrillation were described as regular (p O.l for both comparisons). Fibrilla-
y = 12 - 0.3x
I3
10 El
1
q
R = 0.33
pz.04
El
FtGURE 1. Relation between tachycardia scale and actual tachycardia cycle length in 40 episodes of induced reciprocating tachycardia. There was a weak negative relatkm between tachycarda scale and tachycardla cycle length.
300
400
tachycardia
y =
- 233
cycle
+ 0.8x
length
R = 0.81
p=.OOl
3000
FIGURE 2. Reproducibility
of techycardia scale within patids. An in&x for each tachycardll was determined by multiptying tachycarch scale by tachycardii cycte length. Thsre was a strong retation between index of the first and second tachycardia (p = 0.001).
b
2000
1000
0 1000 Index FIGURE 3. Box plot comparing the coefficient of vaffatktn (CV) in patieds with fiWlatlon eplsedes described as regular (reg) and irregular (irreg). In this plot, a* feriik denotes median value, ad beudarks of the box, the interqIartite range. . CeeffbM of variation of RR intervals was s~bdantidly higher, with fibrillatlm eplsades demfbed as irrsgubr (2 - 2.465, p = o.Ooq.
2000 for
tachycardia
3000 2
5 -I
CV(req) CV(irreg)
x X
X
BRIEF REPORTS
965
tion episodes described as irregular had a substantially higher RR interval coefficient of variation than the fibrillation episodes described as regular (23 f 7 compared with 14 f 6%, p = 0.008, Figure 3). There was no significant relation between either the mean RR or the minimal RR interval of the fibrillation episodes and the tachycardia scale.
In this study nearly all episodes of reciprocating tachycardia were described as regular. In contrast, only half the fibrillation episodes were correctly described as irregular. Therefore, the observation that sustained continuous palpitations are irregular is likely to be fairly specific but insensitive for the diagnosis of atria1 fibrillation. As might be expected, the patient’s awareness of whether a tachycardia was irregular was clearly dependent on the actual irregularity of the heart rate but not directly on the tachycardia rate itself. The irregularity of fibrillation may vary considerably depending on autonomic factors, the atria1 fibrillatory rate and properties of the atrioventricular node.5 Some episodes of fibrillation may be minimally irregular and thus mistakenly perceived as regular by the patient. A linear scale from 1 to 10 was not useful in assessing tachycardia rate because of the marked inter-patient variation. The perception of heart rate is likely to vary considerably for a number of factors. The reproducibility of this
966
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
68
scale within patients, however, was reasonable (Figure 2). Because these results were obtained in the electrophysiologic laboratory, in a select population, they may be not reproduced with spontaneous clinical arrhythmias in other patient populations. In this setting, it was not possible to evaluate other factors such as tachycardia duration, onset characteristics and precipitating events that may be helpful in the clinical diagnosis of palpitations. Nevertheless, these data suggest that a history of sustained irregular palpitations is fairly specific for atria1 fibrillation. A history of regular palpitations could be obtained with both paroxysmal atria1 tachycardia and atria1 fibrillation. 1. deLeon AC, Cheng TO. History and physical examination. In: Chew TO, ed. The International Textbook of Cardiology. New York: Pergannon Books, 1986:22-48. 2. Goldman L, Braunwald E. Cheat discomfort and palpitation. In: Wilson JD, Braunwald E, Isselbacher KJ, Petersdorf RG, Martin JB, Fauci AS, Root RK, eds. Harrison’s Principles of Medicine. New York: McGraw-Hill, 1991;98-105. 3. Braunwald E. The history. In: Braunwald E, ed. Heart Disease. A Textbook of Cardiovascular Medicine. Philadelphia: WB Saunders, 1988:1-12. 4. Leitch JW, Klein GJ, Yee R, Murdcck C. Prognostic value of electrophysiology testing in asymptomatic patients with Wolff-Parkinson-White pattern. Circulation 1990;82:1718-1723. 5. Chorro FJ, Kirchhof CJ, Brugada J, Allessie MA. Ventricular response during irregular atria1 pacing and atria1 fibrillation. Am J Physiol 1990;259:L1015H1021.
OCTOBER
1, 1991
