@
ELECTROCARDIOGRAM OF THE MONTH
Wenckebach Phenomenon with Nodal and Ventricular Escape
in Marathon Runner
Brig. General Orhun Sargin, M.D.,* Lt. Colonel Cengiz Alp, M.D.,OO
Lt. Colonel Cemal Tansi, M.D.,f Captain Levent Karaca, M.D.ff
A 27-year-old gendarme non-mmmlasioned officer,
170 cm in height, ran 5 to 10 kilometers a day
regularly during 196&1963, and has been running
30 to 60 kilometers per day since for Olympic and
Marathon racing training. He has no complaints. His routine check-up revealed, however,
certain interesting indications which have given
occasion to this report.
His family and past history were unremarkable.
He has been in good general health. Before running, while resting, all clinical examinations gave
normal results, with the exception of alterations in
intensity of first heart sound, dysrythmia and bradycardia, all of which disappeared after running
and administration of atropine.
Physical examination and laboratory findings ( 1)
before running, (2) after running 40 kilometers
within a period of three hours in humid conditions
and no sunshine at an altitude of 860 meters above
sea level, are as follows:
'Director and Clinical Professor, The First Medical Clinic,
Giilhane Military Medical Academy, Ankara, Turkey.
"Internist and Instructor, The First Medical Clinic.
+Chief Resident, The First Medical Clinic.
t +Resident. The Rinchemistw Institute.
FIGURE1. Teleoroentgenography before running.
Before running
60.4
Body Weight (Kg) ......
Blood pressure (mm Hg)
Lying down ......... 120/80
Sitting .............. 120/80
Standing ............ 120/80
Pulse per minute
Lying down ......... 50
Sitting .............. 50
Standing ............ 52
Arterial Blood pH ...... 7.39
Arterial Blood p02
(mm Hg) ........... 95
Arterial Blood pC02
(mm Hg) ............ 40
Arterial Blood Standard
bicarbonate (mEq/L) . 23.25
Vital capacity (ml) ...... 4100
Maximum breathing capacity
L/Min) ............. 62.200
Blood sugar (mg%) ..... 84
Cholesterol total (mg!&). . 206
Lipid total (mg%) ...... 582
Lactic acid in blood
(m&)
. - . ............... 2.6
Serum Na (mEq/L) ..... 150
Serum K (mEq/L) ..... 4.6
Serum Ca (mEq/L) ..... 5.4
Serum C1 (mEq/L) ..... 104
17-Hydroxy steroid in urine
(mg/L) .............. 6
Teleoroentgenography Cardiac silhoutte
and
is normal maxiFluoroscopy
mum in size according to cardiothmasic index.
After running
57.9
9
Convexity of the
left ventricular
border relatively
diminished and
in a normal diameter according to cardiothoracic index.
An electrocardiogram taken before running (Fig
3) shows increasing vagal tone which effects the
Keith-Flack and the Aschoff-Tawara nodes: (1) sinus bradycardia; (2) the Wenckebach phenomenon
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21487/ on 06/15/2017
WENCKEBACH PHENOMENON IN MARATHON RUNNER
FIGURE2. Teleoroentgenography after running.
in leads Dl, Dll, Dlll, aVR, aVL, aVF, V2 and VI;
(3) the Wenckebach phenomenon with ventricular
escape in leads VaR, V1, Va and the Wenckebach
phenomenon with nodal escape in leads Va, Va; (4)
type A or T waves with early repolarization.
The electrocardiogram following running 40 kilometers in three hours (Fig 4) shows decrease in va-
gal tone and increase in ventricular beat rate per
minute and disappearance of the Wenckebach
phenomenon. The sinus bradycardia reverted to
normal; in leads Vl, Vz the pattern RSr incomplete
right bundle branch block was observed.
In the electrocardiogram taken during rest, 24
hours after running (Fig 5), under the iduence of
vagal tone, we noted sinus bradycardia, Wenckebach phenomenon in leads Dill, aVR, aVL, VaR,Va,
Va, the Wenckebach phenomenon with nodal escape in leads Dl, Dll, V,, V6 and the Wenckebach
phenomenon with ventricular escape in leads aVF,
Vl; normal atrioventricular conduction in lead Vz;
and T waves with early repolarization in all leads.
After intravenous administration of 1mg atropine
(Fig 6) ventricular beat rate per minute increased
as a result of the decrease of vagal tone. The
Wenckebach phenomenon and incomplete right
bundle branch block patterns disappeared and the
sinus bradycardia reverted to normal.
It is difficult to determine the boundaries of physiologic and pathologic electrocardiographic changes
in the hearts of sportsmen characterized by bradycardia, increase of heart volume and forceful heart
contractions associated with exercise with static
CHEST, VOL. 57, NO. 1, JANUARY 1970
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21487/ on 06/15/2017
~GURE
5
CHEST, VOL. 57, NO. 1, JANUARY 1970
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21487/ on 06/15/2017
WENCKEBACH PHENOMENON IN MARATHON RUNNER
and especially dynamic efforts.
The chief changes in the electrocardiogram of the
heart of sportsmen are as follows: ( a ) first degree
atrioventricular block; ( b ) the Wenckebach phenomenoa; ( c ) transient incomplete right bundle
blaL; and
ST and
related to adaptation and form situation of the
bradl
The Wenckebach phenomenon with nodal and
ventricular escapes and the pattern of changing
incomplete right bundle branch block are very
rarely encountered in the sportsman's heart.
Reprint re uests: Brig Gen. Orhan Sargin, First Medical
Clinic, cukane Turkish Military Medical Academy, Ankara, Turkey
ORIGINAL DESCRIPTION OF THE RHEUMATIC NODULE
In 1904, Ludwig Aschoff (1866.1942) of the University of Marburg, Germany, described an entity
which forever will be associated with his name: the
peculiar nodule specific for rheumatic myocarditis.
These nodules re lady occur in the neighbourhood
of small or me 'um-sized vessels, and were most
frequently present in the vicinity of the adventitia. Or
there existed simultaneously a disease of all vascular
layers, such as is described in arteritis nodosa. The
aforementioned nodules are unusually small, mostly
submiliary, and originate by the conglomeration of
large elements, with one or more abnormally large
indented or polymorphic nuclei. The arrangement of
the cells frequently occurs in the form of a fan or
a rosette. The eriphely is formed by the large nuclei,
the center b" f;le paler or colorless appearing necrotic
8'
mass of confluent cell protoplasm. By cursory examination, the fan formations slightly resemble the necrosis of gout with a peripheral cell mantle, as is so
uently observed in the gouty kidney. The rheumatic
n ules are not to be confused with tubercles or foreign
body cells with more uniform1 formed nuclei. In all
events, the nodules do not exc usively consist of such
large nucleated cells, but also small and large lymphocytes, and polyrnorphonuclear leukocytes force themselves a short distance between the large cells of the
periphery or form a peripheral zone, and from there,
irregular projections may extend far into the connective tissue partitions.
Aschoff, L. in Willius, F.A. and Kevs, T.E.:
Classics of Cardiology, Dover,
New York, 1941
h3
CHEST, VOL. 57, NO. 1, JANUARY 1970
Downloaded From: http://publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21487/ on 06/15/2017
I