Sinoatrial Heart Block with Wenckebach

Phenomenon*
RICHARD J. GREENWOOD, M.D., DAVID FINKELSTEIN, M.D., F.A.C.C. and RICHARD MONHEIT, M.D.

Philadelphia, Pennsylvania

E ARRHYTHMIA to be discussed, sinoatrial There was no venous distention and the examination
T heart block with Wenckebach
enon, is frequently unnoticed
phenom-
by the subject.
of the chest revealed only fine rales at the right base.
The blood pressure was 110/70 mm. Hg with a
regular pulse of 68 beats per minute. The heart
Its detection and significance may escape the
was not enlarged; there was a grade 2 basal systolic
physician not alerted for its occurrence.
murmur. The painful right hip was found to be due
Sinoatrial heart block has been known to to hypertrophic arthritis. An electrocardiogram
the medical profession since MacKenzies de- revealed a sinus rhythm, evidence of old inferior
scription in 1902.l The Wenckebach phenom- myocardial infarction and an intraventricular con-
enon in sinoatrial heart block has appeared duction disturbance.
to be of greater rarity than the simple omission He was readmitted to the hospital in September
of complete heart beats. In 1906 Wenckebach2 1959 because of increasing dyspnea. During the
and later, in 1908, RihP described such a preceding two months he had experienced an an-
terior myocardial infarction; recovery was unevent-
physiologic mechanism quite clearly. These
ful except for moderate congestive heart failure re-
were reiterated later by Wenckebach and
quiring maintenance doses of digitalis. He had
Winterberg. 4 The occurrence of the Wencke-
stopped taking the digitalis in late August. Al-
bath type of block in this arrhythmia is not though he had been seen by his doctor and treated
too surprising in view of the frequency with with a diuretic early on the day of admission, severe
which it is noted in other types of cardiac dyspnea developed upon arrival in the lobby of the
conduction disorders. The paucity of reports hospital. He became cyanotic, had a convulsion
would suggest that this arrhythmia is quite and was in apparent cardiac arrest. Immediate
rare but this does not appear to represent the blows to the chest followed by a 300 ml. phlebotomy
true incidence of this abnormal rhythm. We and nasal administration of oxygen produced recovery
from the acute episode. After being transferred to his
have seen four cases within a period of only a
room, intravenous digitalization was initiated.
few months, three of them of clinical importance.
Physical examination at this time revealed an irregular
This arrhythmia may be associated with the
tachycardia of 120 beats per minute with a blood
intake of digitalis and probably represents a pressure of 110/80 mm. Hg. Respirations were 32
toxic cardiac effect of the drug. The clinical per minute with bilateral moist rales up to the
similarity to a sinus arrhythmia in spacing and apices. The liver was tender and enlarged and
rate underlines the need for careful clinical scrotal and pretibial edema were noted. He re-
and electrocardiographic observation of the ceived a total of 1.2 mg. of deslanoside within the
patient receiving digitalis. The following cases next three hours.
demonstrate the diversity of clinical mani- The electrocardiogram revealed a variable rhythm
with sinus beats interrupted by multiple supraven-
festations of the disorder.
tricular extrasystoles, periods of 2:l sinoatrial block
and periods of paroxysmal atria1 tachycardia (160
CASE REPORTS beats per minute) with a 2:l block. Further digi-
CASE 1. An eighty-two year old man was first talis was withheld. The next morning the patients
admitted to the hospital in 1957 because of pain on congestive failure was worse and digoxin (1 mg.
motion of the right hip. He had suffered an inferior over the succeeding twenty-four hours) was admin-
myocardial infarction in 1955. He denied having istered. The electrocardiogram taken the next
any symptoms of heart failure or angina. General morning revealed occasional supraventricular extra-
examination revealed a well oriented, elderly man. systoles with a sinus rhythm at a rate of 70 beats per

* From the Graduate Hospital and School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

140 THE AMERICAN JOURNAL OF CARDIOLOGY

 Sinoatrial Block 141

FIG. 1. Case 1. The upper strip of the continuous lead V3R is diagrammed and shows two episodes of 5 :4 sinoatrial
heart block with the Wenckebach phenomenon. The diagram assumes an 0.08 second initial conduction between
sinoatrial node and atria1 muscle. The middle strip shows a single 9 :8 response which requires a nearly ten second
recording for its demonstration. Note that while the P-P and R-R intervals become shorter until a dropped beat
occurs the P-R interval does not change. In the lower strip lead 111shows the same mechanism with 6:5 and 5:4
response.

minute. The condition of congestive failure seemed tricular coupled extrasystoles and more classic
improved and a review of the electrocardiograms evidence of digitalis toxicity.
strongly suggested digitalis toxicity; therefore, no
further digoxin was given for three days. However, CASE 2. A seventy-five year old woman had mul-
it gradually became obvious that diuretics were not tiple hospital admissions since 1933. Initially she
sufficient to control the failure and administration of had no clinical evidence of cardiovascular disease.
digoxin was resumed at a dose of 0.25 mg. daily. The first electrocardiogram, taken in 1950, revealed a
Three days later the tracing shown in Figure 1 was sinus tachycardia of 100 beats per minute with mul-
obtained. The following day a ventricular bigeminal tiple extrasystoles. In 1952 the patient was given
rhythm was observed and administration of digoxin digitalis because of mild heart failure, and subsequent
was stopped. As before, congestive failure developed electrocardiograms in 1954 revealed a rate of 85 beats
slowly despite diuretics and after a lapse of five days per minute with occasional atria1 extrasystoles. In
digoxin was again administered at a dose of 0.25 mg. 1957 she began to experience occasional substernal
daily. Two days later a marked sinus bradycardia pain which was relieved by nitroglycerin, and noted
of 44 beats per minute was observed but long strips occasional episodes of dizziness. She exhibited signs
did not reveal confirmatory evidence for sinoatrial of moderate right heart failure. The clectrocardio-
heart block. The bradycardia reverted spontaneously gram revealed a basic rate of 75 beats per minute
the next day to a sinus rate of 70 beats per minute with multiple episodes of 2:l sinoatrial heart block.
with only occasional ventricular extrasystoles at a Subsequent tracings revealed a bigeminal rhythm,
fixed coupling. similar to parts of Figure 2, suggesting 3 :2 sinoatrial
heart block. ACTH, given intravenously for bursitis
Summary: This elderly man, who had had in the shoulder, did not affect the electrocardiogram,
two myocardial infarctions, was admitted with In 1959 she was admitted for syncope, the attack
severe congestive failure. Immediate treat- having occurred while she was shopping. Examina-
ment reversed an acute episode on admission tion did not reveal any definite cause for the syncope
but the patient exhibited marked sensitivity to and an electroencephalogram was within normal
limits. The earlier findings of slight cardiac enlarge-
digitalis. On one occasion this was heralded
ment and slight right heart failure were again noted.
by the variable sinoatrial heart block illustrated
Digitalis dosage was continued. The electrocardio-
in Figure 1 and on a second occasion by a slow gram revealed a variable sinoatrial heart block with
rate of heart beat which may have been due to Wenckebach phenomenon from 4:3 to 2:l with a
2 : 1 sinoatrial block. On each occasion sub- basic rate of 78 beats per minute.
sequent electrocardiograms revealed fixed ven- She was readmitted in January 1960. She had

JULY 1961
142 Greenwood et al.

ii i i i i i
-v2 . i i i i i i:i i. i:.i-,!

FIG. 2. Case 2. The first two complexes in lead 11 demonstrate a 3:2 sinoatrial heart block with the Wenckebach
phenomenon, and the next three complexes a 4:3 response. Other leads are similar except for lead VI where a 2 :1
sinoatrial heart block without Wenckebach phenomenon is suggested in the first three complexes.

noted mild dyspnea on exertion since her admission vealed an elderly man in no distress with a blood
the year before and had experienced several syncopal pressure of 150/80 mm. Hg and a pulse of 45 beats
episodes of brief duration. She was still taking per minute. There was moderate cardiac enlarge-
digitalis. The examination revealed a febrile woman ment, confirmed by x-ray film of the chest. There
with bilateral rales inthe chest and dullness at the were bilateral crepitant rales at the lung bases and
left base and right midlung field, attributed to good expansion of the chest. The electrocardiogram
bronchopneumonia. The blood pressure was 160/80 revealed a rate of 43 beats per minute with what
mm. Hg. There was no other evidence of congestive were interpreted as atria1 extrasystoles. The short
heart failure. The rate of heart beat was irregular. R-R intervals corresponded to a rate of 70 beats per
The electrocardiogram taken at this time is illus- minute and there was no alteration of the P wave
trated in Figure 2. The bronchopneumonia re- contour between the various beats on observation of
sponded to antibiotic therapy and she was discharged. the short lead strips available. This is more sug-
gestive of intermittent 2:l sinoatrial heart block. In
Summary: An elderly woman, initially given view of the mild failure and electrocardiographic
digitalis for congestive heart failure, to which impression of atria1 irritability, the patient was
she at first responded well, subsequently digitalized preoperatively. A regular rate of 52
had syncope and the electrocardiographic beats per minute developed and he withstood sur-
picture of sinoatrial heart block. It is of gery without difficulty. Postoperatively he experi-
interest that ACTH, given for bursitis of the enced two attacks of precordial pain with syncope.
No definite diagnosis was made for these, though
shoulder, did not affect the heart block.
heart block was suggested by one observer.
CASE 3. An eighty-four year old man was admitted He was readmitted in January 1960 for further
in January 1959 for cataract surgery. He had a cataract surgery. Examination revealed dilated
history of coronary artery disease accompanied cervical veins, bilateral basal rales in the chest, slight
by angina pectoris, fainting from cerebral anoxia and cardiac enlargement and a palpably enlarged liver.
paroxysmal atria1 tachycardia. Examination re- The blood pressure was 220/100 mm. Hg and the

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 Sinoatrial Block 143

/ I I I. I I. / l-f I i I IU- I I I1 I m - /

FIG. 3. Case 3. The upper strip, lead aVL, shows a 6:5 sinoatrial heart block with the Wenckebach phenomenon.
The two middle strips are a continuous tracing of lead V, and show one 5 :4 and one 7 :6 episode, the latter followed by
nodal rhythm. The lowest strip (V,) shows a 6:5 response preceded and followed by nodal rhythm.

umn
FIG. 4. Case 4. Lead II. This strip shows a more complex rhythm. Beginning with the second beat there is a
series of five conducted beats, with slightly varying P-R interval, followed by a nodal escape beat. The diagram as-
sumes an initial 0.08 second conduction time from sinoatrial node to atria1 muscle. Assuming a regular sinoatrial
nodal discharge every 0.51 second, there is a gradual delay in the sequence. The third beat shows a lesser increment of
delay as the diagram is constructed, but may be the result of sinus arrhythmia. Two sinoatrial nodal impulses are
blocked allowing time for a nodal escape. Starting with the eighth beat there is a series of four conducted beats show-
ing a regular increment in sinoatrial-atria1 conduction delay, clearly demonstrating sinoatrial heart block with the
Wenckebach phenomenon. The next beat demonstrates a nodal escape.

pulse was 50 beats per minute and irregular. That CASE 4. A sixty year old woman was admitted in
evening the patient had a sudden attack characterized July 1959 for chronic brain syndrome, complaining
by pain in the left side of the chest, pallor, coldness, of pain in the right hip due to a fracture. She was
profuse sweating and, initially, an unobtainable pulse. psychotic and disoriented; therefore, history was ob-
An electrocardiogram revealed evidence of sinoatrial tained from a relative who stated that the patient
heart block with the Wenckebach phenomenon (Fig. was a diabetic, was hypertensive and had been blind
3). Serial electrocardiograms did not reveal any since an unsuccessful operation for the removal of
change except that the evidence of sinoatrial heart cataract had been performed fourteen months
block disappeared as the congestive failure was cor- previously. The family had noted progressive men-
rected with diuretics. The patient maintained a tal deterioration.
regular pulse of 60 beats per minute and digitalis was Examination revealed a regular heart rate of 80
withheld. He was discharged without surgery. per minute and a blood pressure of 178/120 mm. Hg.
X-ray of the chest revealed an increase in the bron-
Summary: This elderly man with severe chovascular markings and cardiomegaly with left
ventricular predominence. The electrocardiogram
arteriosclerotic heart disease had multiple
taken four days after admission (Fig. 4) showed a
syncopal episodes when digitalis was given, but
complex rhythm with evidence of sinoatrial block
felt well on a program of diuretics alone. and Wenckebach phenomenon.
Several electrocardiograms have shown sino- Urinary and wound infection occurred and ter-
atria1 heart block with Wenckebach phenom- minally a staphytococcic, generalized furunculosis
enon. developed. An autopsy was not granted.

JULY 1961
144 Greenwood et al.

Summary: This elderly woman with diabetes shortening of the P-P interval preceding the
had a routine electrocardiogram taken which pause. It is important to re-emphasize that
showed evidence of sinoatrial block and there is no change in the P-R interval. Figure
Wenckebach phenomenon. Serious cardiac dis- 4 represents an exception to this general rule.
ease was not evident until overwhelming urinary As we have shown (Fig. l), there may be a
and wound infection had developed, which long series of beats with the rate becoming
proved fatal. progressively shorter prior to the dropped beat;
therefore, the importance of a long recording
COMMENTS is apparent.
Electrocardiographic Diagnosis: In order to Experimental Work: Eyster, by means of
demonstrate clearly this arrhythmia it is im- mechanical trauma to the area of the sinoatrial
portant to observe the cardiac rhythm over a node, was able to produce periods of sinoatrial
period of fifteen to twenty seconds in the heart block in animals. He showed recordings
electrocardiographic lead where the P waves from the area of the sinoatrial node dem-
are seen best. Several of our cases would not onstrating the formation of electrical impulses
have been diagnosed had only the routine which were conducted to the atria1 muscle with
mountings been observed. a progressively increasing interval of time even
The most important electrocardiographic though the simultaneously recorded electro-
distinction to be made is between sinoatrial cardiogram revealed no evidence of this change.
heart block with the Wenckebach phenomenon These tracings were recorded from the exposed
and sinus arrhythmia. There is no change in the heart by means of pairs of electrodes placed very
atria1 complex, in the P-R interval or in the closely together on the sinoatrial node and
ventricular complex in either rhythm. Slowing atria1 muscle. Other peripheral recordings
of the rate of heart beat with expiration and its showed the typically progressive decrease in
quickening with inspiration are characteristic of the P-P interval and abrupt pause.
sinus arrhythmia. Electrocardiographically, this Eysters work was later criticized by Resniks
may be seen as a gradual lengthening followed because of the technic employed. He did not
by a gradual shortening of the P-P interval, believe that mechanical damage in and around
and, consequently, the R-R interval ; thus, the sinoatrial node was comparable to a
a bellows or accordian type of record is ob- clinical situation, and he utilized pituitary
tained. Sinoatrial heart block may be as- extract injections presumably to increase the
sociated with sinus arrhythmia but in its usual vagal stimulation as his experimental procedure.
form it is characterized by a regular rhythm No electrical records were obtained from the
with the abrupt omission of a complete complex area of the sinoatrial node in this experiment
which results in a space or pause. The kind and the possibility of Wenckebach phenomenon
discussed here, sinoatrial heart block with was not mentioned.
Wenckebach phenomenon, shows a variable More recently, Scherfg injected various solu-
spacing clearly described by Wenckebach and tions into the sinoatrial node and was able by
Winterberg and later by Sir Thomas Lewis.5 this means to precipitate sinoatrial heart block.
The distinction from sinus arrhythmia is Severing both vagus nerves in the neck did not
indicated by the progressive decrease in the prevent the appearance of the block. He
P-P interval with no succeeding gradual in- believed that there is reflex inhibition of the
crease, but, instead, an abrupt omission of the sinus node centers due to the mechanical
entire heart beat. The failure to show a stimulus and did not consider that the nature of
progressive increase, as in sinus arrhythmia, the injected substances was important in pro-
and the presence of a pause has led to the ducing the block.
development of criteria for the electrocardio- Kischo has recently demonstrated in dog-
graphic diagnosis of sinoatrial heart block with fish, in an exhausted, dying heart, the ap-
Wenckebach phenomenon. Winton has stated pearance of combined sinoatrial and atrio-
three criteria : (1) the P-P interval including a ventricular heart block. He recorded the
blocked sinoatrial impulse is shorter than the electrical discharges of the sinoatrial node area
double distance of the P-P interval preceding and observed a progressive lengthening of the
it; (2) the P-P interval after the dropped sinoatrial-atria1 muscle interval. In a slightly
sinoatrial impulse is longer than the interval febrile rabbit he discovered that morphine,
preceding the pause; (3) there is a gradual pressure on the larynx and reflexes from the

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 Sinoatrial Block 145

respiratory tract produced sinoatrial heart the postulation of sinoatrial nodal impulses
block.ll Kisch believes that, as in this unusual from the spacing of the P waves in the electro-
rabbit, both increase in vagus tone and some cardiogram. Experimental recording has re-
underlying nodal pathology are involved in vealed a progressive increase in conduction time
producing the manifestation of sinoatrial heart from sinoatrial node to atria1 muscle, or even
block. complete sinoatrial node and atria1 muscle
There is no experimental evidence deciding dissociation, without change in the P wave
the question of whether clinically observed in the peripheral electrocardiogram. The
sinoatrial heart block is the result of structural or nature of the Wenckebach phenomenon in
functional changes. It is worth noting that the sinoatrial heart block requires the increment of
best demonstrations of sinoatrial block are increase in conduction time of each successively
obtained when the atrioventricular nodal pace- delayed impulse to be less than the increase in
maker is sufficiently depressed so that it does not the preceding conduction time. This results in
assume control of the heart. the arrival time of the P waves coming closer
Clinical Reports: No attempt has been made together and a quickening of the heart rate.
to summarize the entire literature on sinoatrial As this is the mechanism of the block, De-
heart block since the communication by Zardays description I4 that the P-P interval
Barlowi in 1927 which brought the total progressively increases up to the point of the
number of reported cases to fifty-four. In a dropped beat in sinoatrial heart block with
descriptive report Blumberger13 demonstrated Wenckebach phenomenon cannot be accepted.
an unequivocal case of sinoatrial heart block Re-examination of his electrocardiograms with
with Wenckebach phenomenon in a fifty year the assumption of a more rapid rate of sinoatrial
old man receiving no drugs. He clearly node discharge permits the above criteria for
described the mechanism of this type of sino- the Wenckebach phenomenon to apply and
atria1 heart block. explains his electrocardiograms by postulating
DeZarday14 reported two cases of sinus block, more than one dropped beat.
and in one case he noted a gradual increase in The alternative explanation for the clinically
the P-P interval up to the time when the dropped observed pauses is the complete failure of
beat occurred. He believed that this gradual generation of the sinus node impulse. It
increase was a condition necessary to the should be made clear that the coexistence of
Wenckebach phenomenon. The nature of this sinus arrhythmia may make delineation of the
concept is easily understood when it is rec- peculiar spacing of sinoatrial heart block with
ognized that there is no electrocardiographic Wenckebach phenomenon difficult. Although
deflection at the time of sinoatrial nodal dis- the experimental work cited, when it has
charge. The electrocardiogram demonstrates included direct recordings from the sinoatrial
the discharge occurring in the atria1 and ven- node area, has demonstrated sinoatrial nodal
tricular muscle and records the repolarization impulses which were not conducted, the
in these muscles. However, there is no electro- clinical possibility of failure of impulse for-
cardiographic indication of impulse formation mation cannot be excluded with certainty in
in the sinoatrial or atrioventricular nodes or the absence of such direct recordings. It
in the Purkinje fibers. With the common seems doubtful, however, that the absence of a
concept that the P-R interval is accounted for single impulse could account for the preceding
wholly by the atrioventricular node delay, mathematical acceleration of the cardiac rhythm
demonstration of nodal phenomenon in the consistently observed in this variation of
electrocardiogram may be initially suggested. sinoatrial heart block although in the absence
Careful consideration will, however, reveal of Wenckebach phenomenon it is as reasonable
that in the individual case, with each peculiar an explanation as any other. For these reasons,
pathology, there is no available technic to then, we do not believe that this mechanism
confirm what electrical events transpire during applies to our patients.
isoelectric periods. This is true of the sinoatrial Relationship to Drugs: In many cases of
node, in which electrical activity is not ob- sinoatrial heart block digitalis has been ad-
servable clinically and has seldom been recorded ministered. Three of our patients also had
experimentally. received this drug. In some of these cases there
Elucidation of the nature of the Wenckebach was evidence later of more characteristic
phenomenon in sinoatrial heart block requires arrhythmias suggesting that the appearance of

JULY 1961
146 Greenwood et al.

sinoatrial heart block with Wenckebach phe- nomenon being an early manifestation of digitalis
nomenon had been an early indication of digitalis toxicity is suggested.
toxicity.
The importance of digitalis in producing REFERENCES
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THE AMERICAN JOURNAL OF CARDIOLOGY