The Effect of Hyperventilation on the Normal Adult Electrocardiogram By R. H. WASSERBURGER, M.D., K. L. SIEBECKER, JR., M.D., AND W. C. LEWIS, M.D. With the technical assistance of C. Janet Lloyd The effect of brief hyperventilation on the precordial T waves of 350 normal adults i's described. Evidence is presented that brief hyperventilation initiates a vagal reflex which results in the T- wave inversion. Supportive data are also given to exclude respiratory alkalosis as a possible mech- anism. Caution is advised in interpreting isolated T-wave inversions as indicative of organic heart disease. It is proposed that isolated T-wave inversion be deleted as a criterion for a "positive" exercise test. T RANSIENT or persistent T-wave in- versions in the left and midprecordial unipolar leads have been observed in approximately 10 per cent of apparently healthy, adult Negro males and less commonly in Caucasian adults." 2 This pattern is known as the "juvenile pattern" because of its re- semblance to the T-wave changes observed in infants and young children. The clinical im- portance of these electrocardiographic changes lies in the similarity to those of organic heart disease. Previous reports showed that the T-wave inversions could be abolished by the oral ad- ministration of potassium salts or by pro- pantheline bromide (Pro-Banthine, Searle) given intravenously.1' 2 Hyperventilation, on the other hand, intensified the precordial T- wave inversions and, when the T-wave had transiently become upright, elicited the orig- inally observed T-wave changes. These observations with hyperventilation prompted a study of the electrocardiographic effects of hyperventilation on a number of adult patients who had normal resting electro- cardiograms. In addition, the effects of breath- ing various concentrations of carbon dioxide From the Veterans Administration Hospital and the Department of Medicine, University Hospitals, Madison, Wis. Presented at the 28th Scientific Sessions of the American Heart Association in New Orleans, La., October, 1955. An abstract of the preliminary phases of this study (Wasserburger, R. H., and Lorenz, T. H.: An elec- trocardiographic pitfall-"the juvenile pattern.") appeared in Circulation 12: 787, 1955. and oxygen were investigated to determine whether the observed T-wave changes were due to respiratory alkalosis. The effects of the vagal blocking agent, Pro-Banthine, and the potas- sium ion in abolishing the hyperventilation effect were once again studied. The patients were also evaluated from the emotional stand- point, inasmuch as it has been established" 2 that the patients exhibiting the overt "juvenile electrocardiographic pattern" were tense, im- mature, and often neurotic. MATERIALS AND METHODS Electrocardiograms were taken of 901 patients in the Veterans Administration Hospital, Madison, Wis., between Jan. 1, 1954 and Sept. 30, 1955. Of this total, 350 patients were selected for inclusion in this study on the basis of the following criteria: (1) the presence of a normal resting electrocardio- gram, (2) absence of debility, (3) an age range be- tween 18 and 50 years and (4) no clinical evidence of coronary artery or significant cardiovascular disease. Of this group, there were 258 Caucasians and 92 Negroes; the mean age was 35 years. All electrocardiograms were taken in recumbency, with a direct-writing machine. Hyperventilation consisted of 10 to 15 seconds of forced, rapid respira- tion that was repeated during the recording of each precordial unipolar lead. The patients exhibiting the most marked T-wave changes during hyper- ventilation (positive reactors) were subjected to the following additional studies: 1. Hyperventilation during Inhalation of Variouts Gaseous Mixtures Six patients with the most striking T-wave in- version following hyperventilation were observed during the inhalation of various gaseous mixtures containing low, normal, and high concentrations of oxygen and carbon dioxide. Hyperventilation was 850 Circulation, Volume XIII, June, 1956 by guest on May 12, 2018 http://circ.ahajournals.org/ Downloaded from
Transcript
The Effect of Hyperventilation on theNormal Adult Electrocardiogram
By R. H. WASSERBURGER, M.D., K. L. SIEBECKER, JR., M.D., AND W. C. LEWIS, M.D.
With the technical assistance of C. Janet Lloyd
The effect of brief hyperventilation on the precordial T waves of 350 normal adults i's described.Evidence is presented that brief hyperventilation initiates a vagal reflex which results in the T-wave inversion. Supportive data are also given to exclude respiratory alkalosis as a possible mech-anism. Caution is advised in interpreting isolated T-wave inversions as indicative of organicheart disease. It is proposed that isolated T-wave inversion be deleted as a criterion for a "positive"exercise test.
T RANSIENT or persistent T-wave in-versions in the left and midprecordialunipolar leads have been observed in
approximately 10 per cent of apparentlyhealthy, adult Negro males and less commonlyin Caucasian adults." 2 This pattern is knownas the "juvenile pattern" because of its re-semblance to the T-wave changes observed ininfants and young children. The clinical im-portance of these electrocardiographic changeslies in the similarity to those of organic heartdisease.
Previous reports showed that the T-waveinversions could be abolished by the oral ad-ministration of potassium salts or by pro-pantheline bromide (Pro-Banthine, Searle)given intravenously.1' 2 Hyperventilation, onthe other hand, intensified the precordial T-wave inversions and, when the T-wave hadtransiently become upright, elicited the orig-inally observed T-wave changes.
These observations with hyperventilationprompted a study of the electrocardiographiceffects of hyperventilation on a number ofadult patients who had normal resting electro-cardiograms. In addition, the effects of breath-ing various concentrations of carbon dioxide
From the Veterans Administration Hospital andthe Department of Medicine, University Hospitals,Madison, Wis.
Presented at the 28th Scientific Sessions of theAmerican Heart Association in New Orleans, La.,October, 1955.
An abstract of the preliminary phases of this study(Wasserburger, R. H., and Lorenz, T. H.: An elec-trocardiographic pitfall-"the juvenile pattern.")appeared in Circulation 12: 787, 1955.
and oxygen were investigated to determinewhether the observed T-wave changes were dueto respiratory alkalosis. The effects of the vagalblocking agent, Pro-Banthine, and the potas-sium ion in abolishing the hyperventilationeffect were once again studied. The patientswere also evaluated from the emotional stand-point, inasmuch as it has been established" 2
that the patients exhibiting the overt "juvenileelectrocardiographic pattern" were tense, im-mature, and often neurotic.
MATERIALS AND METHODS
Electrocardiograms were taken of 901 patients inthe Veterans Administration Hospital, Madison,Wis., between Jan. 1, 1954 and Sept. 30, 1955. Ofthis total, 350 patients were selected for inclusionin this study on the basis of the following criteria:(1) the presence of a normal resting electrocardio-gram, (2) absence of debility, (3) an age range be-tween 18 and 50 years and (4) no clinical evidence ofcoronary artery or significant cardiovascular disease.Of this group, there were 258 Caucasians and 92Negroes; the mean age was 35 years.
All electrocardiograms were taken in recumbency,with a direct-writing machine. Hyperventilationconsisted of 10 to 15 seconds of forced, rapid respira-tion that was repeated during the recording of eachprecordial unipolar lead. The patients exhibitingthe most marked T-wave changes during hyper-ventilation (positive reactors) were subjected to thefollowing additional studies:
1. Hyperventilation during Inhalation of VarioutsGaseous Mixtures
Six patients with the most striking T-wave in-version following hyperventilation were observedduring the inhalation of various gaseous mixturescontaining low, normal, and high concentrations ofoxygen and carbon dioxide. Hyperventilation was
REBREATH OWN AIR-REABSORB EXHALED COt.. LOW Ot NORMAL GOt
LATION OF 100% Or-REABSORB EXHALED C0. .*. HIGH O NORMAL COt-iVPESVSISTILATIOW ??%Sa0 7 atedO rWte4
REABSORBED.-. LOW 0. HIGH C O..OO.Setwwae4
INHALATION OF 94.5% Ot-5.5% COt..HIGH Ot HIGH CO.
INHALATION OF 89 % 0a-11 % CO. .-. HIGH O. HIGH CO*
FIG. 1. Lead V4 electrocardiogram during complete hyperventilation study on L. M., 32 year oldNegro. The percentages refer to oxygen saturation. The control tracing, with patient breathingroom air, showed a very active hyperventilation reflex with marked T-wave inversion within 8 sec-onds. This effect persisted while the patient breathed low 02, normal C02; high 02, normal CO2;low 0., high C02; and high 02, high CO2. The T-wave inversion patterns during the inhalation ofexcessive C02 (11 per cent) were shorter than those seen on previous studies.
repeated during the inhalation of each of the 4gaseous mixtures. The unipolar leads with the mostmarked T-wave changes during the control hyper-ventilation were recorded during the administrationof the gaseous mixtures. Continuous monitoringwith a Waters-Conley ear oximeter was carried outduring the period of gas administration to detectchanges in arterial saturation. Arterial blood pH,pCO2 and venous blood potassium concentrationswere not measured.
2. Vagal BlockadeThe effect of a vagal blocking agent, Pro-Ban-
thine, in abolishing the hyperventilation effect wasstudied in 11 instances. Pro-Banthine, (30 mg.diluted in 10 ml. of water) was administered intra-venously in increments of 5 mg. over a 3 to 4 minuteperiod. The endpoint of drug administration wastachycardia of 140 to 150 beats per minute. Hyper-ventilation was subsequently repeated duringmaximal Pro-Banthine activity, usually 45 to 90minutes following the injection, when the drug-induced tachycardia had stabilized at 125 to 130beats per minute.
3. Potassium SaltsThe effect of 10 Gm. of orally administered
potassium salts, (5 Gm. of potassium bicarbonateand 5 Gm. of potassium acetate, diluted in 30 ml.
of water) in abolishing the electrocardiographiceffect of hyperventilation was likewise studied insix instances. Hyperventilation was repeated 30 to 60minutes after ingestion of potassium, the period ofmaximal drug effect.
4. Psychiatric EvaluationTwelve patients had previously been referred for
psychiatric consultation and 11 additional patientswere available for psychiatric study when theevaluation of the emotional factors were under-taken. Twenty-five patients had completed theMadison Sentence Completion Form3 (a test methoddesigned specifically to evaluate the attitudes andemotional reactions of patients with tuberculosis).Therefore, all patients in this study had eitherpsychologic testing or psychiatric evaluation, andmany had both. During the individual standardizedpsychiatric interviews, emphasis was placed on thepatient's personality structure, maturity, and reac-tions to emotional stress.
RESULTST-wave inversions were observed in 37 of
the 350 patients tested by hyperventilation.The T-wave changes were observed in two ormore of the mid and left precordial leads.Twenty-five were Caucasians and 12 were
Negroes (9.5 and 13 per cent, respectively).The mean age of the positive reactors was 32years and was similar in Caucasians andNegroes.
1. Hyperventilation during Inhalation of VariousGaseous MixturesRegardless of the inhaled gaseous concentra-
tion, persistent T-wave inversion was observedupon brief hyperventilation in the 6 patientsstudied. The T-wave inversion, however, thatoccurred during a period of inhalation of 89
_
X a.. ... : .:. .. ............. ..... : :.f ti j .f; 1 At , . ,,4 X - .. : ,i 0 t 0 f .D.s-.
::j:: .v vws. eevoiESo> S s.; ¢.: s:f a. ....... i .............. L s.: P e. , .iS; f 'S5: Rk. .',.:; '};
y 70;" t st'' Rz4.sMo.9wv s^i23
a / / ;g - y 00 i 0: g8-|* i;._ _ *s v 5.;; :S PE '.pe, 7 ; ! _i; , 7 . 5 ' ' i 0 ' 57: :: :: :0 t: iV:0: i '::. :i::7:: L.,,: ;.,::,; ,:X ........ .:
;ff''''V ;S'wDe;< S':;$' tyt.f0' 'DXA'>X,,, X,,, F ... S >-r 0 s .we . * ..
8-27-54,
: 4?-54
8-27-54
6-27-84
per cent oxygen and 11 per cent carbon dioxidewas of shorter duration. The effect of hyper-ventilation was not so great during this period,apparently because of the narcotizing effect ofthe high concentration of CO2. Oxygen satura-tion increased uniformly during the period ofhyperventilation in all gaseous atmospheres(fig. 1).2. Vagal Blockade
Complete abolition of the hyperventilationeffect by Pro-Banthine was observed in 8 of
V2 V3 V4 vs V$
ON TRACING
it,. . ...
I5)~.'.i-~
.H -3_nii
_
J ...i.. ..* s . X .
--D_
tACIN<3
HYPERVENTILATION
FIG. 2. A 26 year old Negro. Electrocardiograms on 8-10-54 and 8-27-54 were normal. MarkedT-wave inversions, V3 through V5, followed hyperventilation and disappeared after Pro-Banthine.The tracing of 11-8-54 was normal and marked inversions of T waves in V3 and V4 followed hyper-ventilation.
EFFEtCT OF HY1PEI{VENTILATION ON ElECTROCARI)IOGRAMS
under tension. The unsuccessful nature of thepatients' defense against anxiety was striking.Their relations with others had a distinctlyimmature flavor. Compulsive (om01pliance wasthe most (common method of handling aggres-sive feelings. It would appear that the "juve-nile pattern" in the electrocardiogram has itsemotional counterpart in a particular formn of"juveniility" of personality.
DIscussioSN
1\Iuch stress is placed on the diagnostic andprognostic significance of isolated T-w-aveinversions.4-6 Indeed, one of the principalcriteria of an abnormal exercise test is a re-versal in polarity in the precordial T waves.7-9Such T-wave inversions have been observedas a benign "juvenile patterni" in apparentlynormal, young, Negro males. This pattern isnevertheless frequently misinterpreted as show-ing coronary, myocardial, or pericardial dis-ease.The overt "juvenile pattern" has l)een
found in approximately 10 per cent of adultNegro males, though it is relatively rareamong Caucasian males.2 It appears from thepresent study that the pattern is latent inboth Negro and Caucasian males. The latentform can be demonstrated by subjecting thepatient to a brief period of hyperventilation.With this technic it was found in 13 per centof the Negro and 9.5 per cent, of the Cau-casian patients.
It has been suggested that the T-wave in-versions during hyperventilation were due torespiratory alkalosis.1"-l4 The promptness withwhich the pattern follows initiation of hyper-ventilation and the appearance of the patternduring inhalation of high concentrations of CO2exclude this mechanism.The hyperventilation effect may be ex-
plained as a vagal reflex arising in the thorax,similar to the Hering-Breuer reflex. Supportis given to this concept by the blockade of theeffect by Pro-Banthine or potassium.
Psychiatric evaluation of these patientsshowed them to be tense, immature, and emo-tionally disturbed. They expressed muchinner hostility, yet exhibited external passiv-ity, and they met stressful ,situations with
compulsive compliance. The T wave thereforemight, well be regarded as the ",stress segment"of the electrocardiogram.
SUMMARYThe electrocardiograms of 350 normal adult
males were studied following brief hyperven-tilation.
In 37 patients, T-wave inversions were ob-served ini two or more of the precordial leads.This phenomenon is regarded as a latent"juvxeniile pattermn."
Psychiatric e'valuation of these patientsrevrealed them to be teimse, immature and emo-tionally disturbed. ".Juvenility" is expressedin their personality structure as well as intheir electrocardiogram.
Respiratory alkalosis was excluded as theunderlying mechanismn by observation of thepatter(d(uring forced breathing of high (C02atmospheres.The hyperventilation effect is believed due
to a v-agal reflex. Support is given this conceptby demonstration of the blocking effect ofPro-Banthine and potassium.
Caution is advised in interpreting isolatedT-wave inversions as indicative of organicheart disease, particularly in emotionallydisturbed, tense individuals. It is proposedthat isolated T-wave inversioni be deleted as acriterion for a "positive" exercise test.
ACKNOW\\LEDGMENTThe authors wish to express their appreciation to
Forrest .J. Fischer and Thomas L. 'Marlar for theirvaluable photographic assistance.
SUMMARIO IN INTERLINGUA
Le electrocardiogrammas de 350 normaladultos mascule esseva studiate post brevehyperventilation. In 37 subjectos, inversionesdel utnda T esseva observrate in 2 o plus deriva-tiones precordial. Iste phenomeno es (coinSi-derate ( om(o un latente "configuration jtuvenil ."Le evalutation psychiatric del subjectos reve-lava clue illes esseva tense, immatur, e emio-tionalmente disturbate. "JJuveniilitate" es mani-feste in le structura de lor personalitate tantoben como in lor electrocardiogramma. Alcalo-sis respiratori esseva excludite como mecha-nismo sulfjacente proque le configuration se
observava durante le respiration fortiate deaere a alte contento de CO2. Le effecto delhyperventilation es debite in nostre opinion aun reflexo vagal. Iste conception es supportateper le demonstration de un effecto blocantede Pro-Banthina e kalium. Nos recommendaprudentia in interpretar isolate occurrentiasde invertite undas T como indication deorganic morbo cardiac, specialmente in tensee emotionalmente disturbate individuos. Nospropone que le occurrentia isolate de invertiteundas T es supprimite como criterio de "posi-tivritate" in tests de exercitio.
REFERENCES1 WASSERBURGER, R. H.: Observations of the
2, AND LORENZ, T. H.: The effect of hyperventila-tion and Pro-Banthine on isolated RST segmentand T-Wave abnormalities. Am. Heart .1. Inpress.
3 CALDEN, G.: A method of evaluating the attitudesof tuberculous patients. Am. Rev. Tuberc. 67:722, 1953.
4 PRUIrr, R. D., KLAKEG, C. H., AND CHAPIN, L. E.:Certain clinical states and pathological changesassociated with deeply inverted T-waves in theprecordial electrocardiogram. Circulation 11:517, 1955.
'SCHLANT, R. C., Li.VIN:}E, H. 1)., AND BAILEY,C. C.: Isolated T-wave negativity in the"ischemic phase" of my ocardial infarction inman. Circulation 10: 829, 1954.
5 ROCHLIN, I., AND EDWARDS, W. L.: _Misinterpre-tation of electrocardiograms with post-prandialT-wave inversion. Circulation 10: 843, 1954.
YU, P. N. G., AND SOFFER, A.: Studies of electro-cardiographic changes during exercise (modi-fied double twvo-step). Circulation 6: 183, 1952.
8 KLAKE}G, C. H., PRUITT, R. D., AND BURCHELL,H. B.: A study of electrocardiograms recordedduring exercise tests on subjects in the fastingstate and after the ingestion of a heavy meal.Am. Heart .J. 49: 614, 1955.
9MASTER, A. M1., PORDY, L., AND CHE.SKY, K.:Two-step exercise electrocardiogram. J.A.A.151: 458, 1953.
10 LEWIS, B. I.: The hyperventilation syndrome.Ann. Int. -Med. 38: 918, 1953.
11 UNGERLEIDE1R, H. E., DUHIGG, T. F., AND GUB-NER, R. S.: Examination of the heart in navyapplicants. U. S. Naval 'M. Bull. 41: 441, 1943.
12 BARKER, P. S., SHRADER, E. L., AND RONZOMI, E.:The effects of alkalosis and acidosis upon thehuman electrocardiogram. Am. Heart J. 17:169, 1939.
13 PRINZMIETAL, M., AND MIASSUMI, R. A.: Theanterior chest wall syndrome. .J..M.A. 159:177, 1955.
http://circ.ahajournals.org/content/13/6/850located on the World Wide Web at:
The online version of this article, along with updated information and services, is
http://circ.ahajournals.org//subscriptions/
is online at: Circulation Information about subscribing to Subscriptions:
http://www.lww.com/reprints Information about reprints can be found online at: Reprints:
document. Permissions and Rights Question and Answer
of the Web page under Services. Further information about this process is available in thewhich permission is being requested is located, click Request Permissions in the middle columnClearance Center, not the Editorial Office. Once the online version of the published article for
can be obtained via RightsLink, a service of the CopyrightCirculationoriginally published in Requests for permissions to reproduce figures, tables, or portions of articlesPermissions:
