Repetitive paroxysmal ventricular tachycardia.

Case 1. A man, aged 22, was first seen as an out-patient in May, 1958. He complained of dyspnoea on strenuous exertion but was able to lead a normal active life for a man of his age. He had never been conscious of palpitation. His heart action was known to have been irregular since childhood but otherwise he had had no relevant illness; no previous electrocardiogram had been recorded. On clinical examination, apart from obesity (weight 15 st. 7 lb.; height 6 ft.) his general condition was excellent. The peripheral pulse was slow and irregular with an approximate rate of 24 a minute. Inspection of the neck revealed intermittent bouts of rapid irregular venous waves, each bout terminating in a precipitous y descent. On auscultation a gross arrhythmia was present which defied analysis. The blood pressure was approximately 140/85 mm. Hg. There were no other clinical findings of note. A chest X-ray showed a large heart with a cardio-thoracic ratio of 60 per cent. Extracts from his first electrocardiogram are shown in Fig. 1. In view of these findings he was admitted to hospital where he stayed for one week. Quinidine sulphate 0 4 g. t.d.s. immediately suppressed the arrhythmia and he remained in sinus rhythm for the next five weeks. It was then noted that although sinus rhythm was present when supine, numerous extrasystoles, often in runs, occurred on standing. Six weeks after his discharge, the original arrhythmia had returned despite continuance of quinidine and he was re-admitted to hospital for further investigation. All therapy was omitted over a period of ten days while a number of investigations were carried out. Throughout this period the arrhythmia persisted day and night without intermission and without distress to the patient. Quinidine therapy was then restarted and sinus rhythm was again immediately restored. By the end of six weeks the cardio-thoracic ratio had fallen to 46 per cent, the cardiogram was physiological, and no evidence of structural heart disease could be found. He was again discharged from hospital to continue quinidine therapy as an out-patient. During the next four months he was almost always found to be in sinus rhythm but repetitive runs of ectopic beats could usually be provoked by brisk exertion (e.g. jumping for one minute) and would persist for several minutes. In February 1959 quinidine was discontinued on account of side effects. After two to three months arrhythmia at rest reappeared but in less florid form. During the past two years he has been able to work regularly without medication despite the continued presence of the arrhythmia and a return of cardiac enlargement.