The history and contributions to treatment of arrhythmias and syncope

The Irish Cardiac Society (ICS) Annual Stokes Lecture was this year delivered by Dr Janet McComb, Consultant Cardiologist at the Freeman Hospital in Newcastle, UK, on the topic of ‘Stokes, Adams, Ward and Many Others: Arrhythmias and Syncope’. Dr McComb’s talk was warmly received by delegates, who heard about the historical importance of the work of Prof Robert Adams, a pioneering surgeon in the 1800s, and she presented a number of case studies to illustrate the treatment methodologies at that time.

Dr McComb also outlined some of the work of Prof William Stokes, including historical case studies in patients with recurrent syncope and suspicious cardiac pathologies that, even at that time, “presented red-flags for cardiovascular disease,” Dr McComb told the packed auditorium. This early work formed the genesis of diagnostic criteria for Stokes-Adams Disease, she told the attendees.

She also provided a brief outline of the work of Prof Conor Ward, who made many significant contributions to the field of paediatric cardiology. “Prof Ward was called ‘an irrepressible advocate for patients’, which I think is a lovely and fitting tribute and must be one of the highest compliments that can be given in medicine,” Dr McComb told the meeting.

She also outlined the early diagnostic and trial-and-error nature of historical pharmacological treatments for arrhythmias and syncope and the early identification of familial syndromes.

“Adams attacks were originally described as attacks of recurrent syncope with little or no warning, possible injury, quick recovery and profound bradycardia. AV [atrioventricular] block was shown and that was assumed to be the only mechanism. Subsequently, however, other arrhythmias — particularly sinus arrest, self-terminating ventricular tachycardia and/or fibrillation — were shown to cause identical symptoms,” she explained.

Dr McComb also traced the development of early pacemaker implantation and displayed the large size and cumbersome nature of these devices, which presented unique challenges to cardiologists at the time of their introduction, and the learning process for physicians implanting them. Dr McComb herself, who trained in Belfast, was one of the physicians who pioneered the use of these devices.

“The original description of Stokes-Adams attacks — made by Stokes, and before him Adams, and before him others almost 200 years ago — still stands,” Dr McComb concluded. “More recently, about 100 years ago, it was recognised that arrhythmias other than heart block can cause these attacks and whether we continue to call them ‘Stokes-Adams attacks’ or ‘arrhythmic syncope’, I don’t know. We shouldn’t just call them ‘cardiac syncope’, because obviously other things related to the heart, such as obstruction, can cause cardiac syncope.

“It is our role to teach and train those who treat patients with syncope to recognise cardiac syncope, and in particular arrhythmic syncope, and to encourage early referral for specialist advice to ensure equity of access to appropriate investigation and therapy.”