Syncope as an indication of digitalis toxicity.

A. H., a 77-year-old woman, was admitted to the Williamsburgh General Hospital on October 5, 1955, with a history of left radical mastectomy for malignant disease 15 years previously with no recurrence to date. Hypertension was of many years' duration. She had shown slight evidences of congestive heart failure some months prior to admission, had been digitalized, and was comfortable on a maintenance dose of 0.2 mg. of digitoxin for a while. Beginning in July 1955 she had noted mild dysphagia, with a feeling of a "lump" behind the sternum after swallowing. For 11 days prior to admission syncope occurred immediately after swallowing water, but not after food. Each episode was manifested by pallor, cyanosis, loss of consciousness, and mild convulsive movements, lasting for a short time. On admission, blood pressure was 200/110, the heart was enlarged, regular, with occasional extrasystoles, and a loud musical murmur was heard at the apex, extending upward over the aortic area. No signs of congestive failure were present. X-ray of the esophagus was normal, and calcification was seen in the abdominal aorta. The electrocardiogram showed left axis deviation, with the "hinge-door" depression of S-T segments indicative of digitalis effect. Q waves in leads II, III, and aVF suggested old damage of the posterior wall of the myocardium (fig. 1). Pressure on the right carotid sinus induced a typical syncopal attack with cardiac arrest and nodal escape. The patient was given a swallow of cold water on 2 separate occasions, and each time she lost consciousness, with a fall in blood pressure to zero, sinus arrest, and nodal or ventricular escape. Each episode, whether induced by swallowing or by carotid sinus pressure, was identical.