Electrocardiographic Abnormalities in Alcoholic Cardiomyopathy A Study of 65 Patients* Tali T. Bashour, M.D.,oO Hamid Fahdul, M.D.,t and Tsung O. Cheng, M.D., F.C.C.P.t
Electrocardiograms of 65 patients with alcoh06c cardiomyopathy seen over a five-year period were reviewed. ST segment and T wave abnonnaUties, left ventricular hypertrophy, biatrial enlargement, left atrial enlargement, premature ventricular contractions, prolonged PR inte"aI, and left anterior hemiblock are the most frequently encountered abaonnaUties. A combination of left ventricular hypertrophy and biatrial enlargement
with or without left anterior hemiblock is most specific. Atrial ftutter or fibrillation, patboJocic Q waves, and bifascicular block are not uncommon fiDdlDp, wblle isolated right atrial or right ventricular abnormaHties, aad isolated posterior hemiblock or right bundle branch block are rare. Electrocanliographic changes are In general similar to those seen in any diffuse cardiomyopathy and reftect biventricular involvement.
The electrocardiographic manifestations of cardiomyopathy have been the subject of several investigations.':" Basically similar abnormalities were found in idiopathic, familial and alcoholic cardiomyopathy.' Few specific myocardial diseases may be associated with high preponderance of a special abnormality such as right bundle branch block in Chagas disease," right axis deviation in Friedreich's ataxia," and a posterior necrosis pattern in Duchenne's muscular dystrophy." In this investigation, we report the electrocardiographic abnormalities in 65 patients with alcoholic cardiomyopathy, an especially conunon disease in our hospital; herein we attempt to establish the general incidence of different electrocardiographic patterns in this homogeneous type of cardiomyopathy.
Washington University Hospital were diagnosed as having cardiomyopathy associated with alcohol abuse. The diagnosis was made on the basis of excessive alcoholic consumption 0 and history, along with clinical, radiologic, and hemodynamic features of diHuse myocardial disease. Patients with diastolic pressure above 100 mm Hg and/or systolic pressure above 150 mm Hg were excluded from this study. Also excluded were those with coronary artery disease and valvular heart disease. The presence and progression of the following electrocardiographic abnormalities were determined from interval tracings averaging six 12-lead electrocardiograms per patient: rhythm disturbances, left atrial enlargement, right atrial enlargement, biatrial enlargement, left ventricular hypertrophy, right ventricular hypertrophy, biventricular hypertrophy, left anterior hemiblock, left posterior hemiblock, left bundle branch block, 6rst degree atrioventricular block, and unde6ned intraventricular conduction defects.
MATERIALS AND METHODS
Between April 1969 and March 1974, 65 patients admitted to the District of Columbia General Hospital and the George °From the Department of Medicine, Division of Cardiology The George Washington University School of Medicine and The George Washington University Medical Division, District of Cohunbia General Hospital, Washington, D.C. 00 Assistant Professor of Medicine (Cardiology), The George Washington University School of Medicine. tFellow in Cardiology, District of Columbia General Hospital. tProfessor of Medicine (Cardiology), The George Washington University School of Medicine; Associate Director, Division of Cardiology, and Director, Cardiac Catheterization Laboratory, The George Washington University Medical Center. Manuscript received July 15, 1974; revision accepted November8. Reprint requests: Dr. Cheng, 2150 Pennsylvania Avenue NW, Washington, D.C. 20037
24 BASHOUR, FAHDUL, CHENG
RESULTS
Our findings are reported in Table 1. Fifty-Six patients were men and nine were women, ages ranging between 21 and 66 years, with an average of 42 years. The average follow-up period was 21.4 months.
Rhythm Disturbance Sinus rhythm was present in 57 patients and eight patients had atrial fibrillation or atrial Hutter. Premature atrial contractions were found in 11 cases; they antedated the development of atrial o Defined
as the repeated drinking of alcoholic beverages to an extent that exceeds customary dietary use or surpasses the social drinking customs of the community. Each patient in our series admitted to regular consumption of at least 4 drinks a day over a period of six years or longer.
CHEST, 68: 1, JULY, 1975
Table I-Incidence 01 Elec'rocardio«raphic AbnormaUde. in 65 Patien,.
ciated with left bundle branch block and in four with right bundle branch block. Left posterior hemiblock was found in three patients, in two of them in association with right bundle branch block. Right bundle branch block was present in six patients; in four it was associated with left anterior hemiblock (Fig I-A) and in two with left posterior hemiblock. Left bundle branch block was found in seven patients (10.8 percent); it was isolated in four and associated with abnormal left axis deviation in three (Fig I-B). Patients with bifascicular block were studied separately with the help of His bundle electrocardiography and are to be reported in another communication. 10 Abnonnally wide QRS complexes atypical for either left or right bundle branch block were present in five patients.
Percent No. of InciPatients dence Rhythm Disturbance:
Premature ventricular con tractions Ventricular tachycardia Premature atrial contractions Atrial fibrillation or flutter
Conduction Disturbance:
1st degree atrioventricular block Left anterior hemiblock Left posterior hemiblock Left bundle branch block Right bundle branch block Intraventricular conduction defect
Atrial Abnormality: Ventricular Abnormality:
24 2 11 8
37 3 17 12.3
22 17 3 7 6
34 26
5
5
10.7 9.2 7.7
Left atrial enlargement Right atrial enlargement Biatrial enlargement
15
23
35
52.2
Pathologic Q Left ventricular hypertrophy Right ventricular hypertrophy Biventricular hypertrophy
3 43 2 3
5 66 3 5
65
100%
Other ST-T changes Abnormalities:
Atrial Abnormalities The most common atrial wave abnormality was a wide and tall P wave in lead 2 with prominent diphasic P wave in lead VI, both consistent with biatrial enlargement (Fig 2). This sign was present in 35 patients (52.2 percent). P waves consistent with left atrial enlargement were found in 15 patients (23 percent) in nine of them in association with left ventricular hypertrophy. In all, atrial ab- . normalities including atrial fibrillation were present in 58 patients (89 percent) .
fibrillation in three patients. Frequent premature ventricular contractions were relatively common, being found in 24 patients (37 percent). Short runs of ventricular tachycardia were documented in two of these patients, one of them having had syncopal attacks. Premature ventricular contractions were generally resistant to antiarrhythmic agents and tended to persist despite effective control of congestive heart failure.
Ventricular Abnormalities Left ventricular hypertrophy was quite common, being found in 43 patients (66 percent), as shown in Figure 2. In all of them the criteria included also ST segment and T waves abnonnalities, although almost all patients were receiving digitalis compounds. Right ventricular hypertrophy was uncommon, being found in only two patients. Three patients had changes consistent with biventricular hypertrophy.
Conduction Disturbance First degree atrioventricular block (PR interval longer than 200 msec ) was present in 22 patients (34 percent). Left anterior hemiblock was present in 17 patients (26 percent); in three it was asso-
Alii .~". I iilil;" F
BIIIIIIIIIIIII FIGURE 1. Two examples of bundle branch block. A. Right bundle branch block is associated with extreme left axis deviation consistent with left anterior hemiblock. B. Left bundle branch block and abnormal left axis deviation are present.
CHEST, 68: 1, JULY, 1975
ECG ABNORMAUTIES IN ALCOHOLIC CARDIOMYOPATHY 25
FIGURE 2. Electrocardiograms of three patients. The first (A) shows left ventricular hypertrophy with P wave abnormality consistent with biatrial enlargement (see text f01' explanation). The second tracing (B) shows the same atrial abnormality in addition to left anterior hemiblock. The third tracing (C) shows prolonged PR interval, left anterior hemiblock, left ventricular hypertrophy, and biatrial enlargement, a combination quite characteristic of cardiomyopathy.
B
Other Abnormalities Variable degrees of ST segment and T wave changes were present in all patients (Table 1); in the majority these were nonspecific, but frequently they were consistent with left ventricular strain or with digitalis effect. Pathologic Q waves were present in three patients who were all below the age of 30 years, and none had history consistent with coronary insufficiency. In one, QS complexes were localized in leads 2, 3 and aVF (Fig 3-A); in the second, in leads VI-V3 (Fig 3-B ); in the third, in leads 1 and aVL. DIscuSSION
Clinical evaluation of primary myocardial disease including electrocardiographic data was reported earlier from our hospital," and other comprehensive reviews of the subject were also reported.':" The purpose of the current report is to add 65 new cases of myocardial disease, all associated with excessive alcoholic intake. While most other reports 2-6.9 included all types of primary myocardial disease, this series deals exclusively with that associated with excessive alcoholic intake, the so-called alcoholic cardiomyopathy. To our knowledge this is the largest series so far published dealing with the electrocardiographic features of this entity. An impressive closeness in the incidence of different electrocardiographic abnormalities is shared by our patients -and those reported by others. A lower incidence of atrial fibrillation was reported by Banta et aI;3 their patients, however, were believed to have idiopathic myocardial hypertrophy and the incidence of alcohol abuse was not mentioned. Our
2& BASHOUR, FAHDUL, CHENG
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:!"
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FIGURE 3. Pathologic Q waves in cardiomyopathy. Tracing A belongs to a 28-year-old patient; it shows Q waves in leads 2,3 and aVF (inferior necrosis pattern). Tracing B shows QS complexes in VI-V 3 (anterior necrosis pattern). Biatrial enlargement is also seen in both tracings, and left ventricular hypertrophy is present in B.
CHEST, 68: 1, JULY, 1975
findings suggest that, regardless of the etiology of diffuse myocardial disease, electrocardiographic changes are similar, a fact that probably reflects similar hemodynamic alterations resulting from widespread myocardial dysfunction. The frequent bilateral atrial abnormalities suggest involvement of both ventricles with either primary or secondary involvement of the atria. A combination of biatrial enlargement and left ventricular hypertrophy (Fig 2) with or without left anterior hemiblock is quite common and most specific. An interesting finding is the rarity of electrocardiographic criteria for isolated right ventricular hypertrophy, although this may be indirectly inferred from right atrial enlargement. We speculate that, since left ventricular forces are dominant on the normal electrocardiogram, this dominance is likely to be maintained when both ventricles are involved equally. In another report from our institution the localization and the prognosis of bifascicular block in these patients were evaluated by His bundle studies, atrial pacing and clinical followup. 10 We found that, despite the common delay in the His-Purkinje system, prognosis was appreciably better than that found in bifascicular block due to coronary artery disease. In comparison with hypertrophic obstructive cardiomyopathy, 12 conduction defects and atrial abnormalities including atrial fibrillation seem to be more, and pathologic Q waves less, common in alcoholic cardiomyopathy. Finally, it is logical to conclude that alcoholic cardiomyopathy results in electrocardiographic changes similar to those produced by other diffuse types of cardiomyopathy, and different from
changes due to more selective types of myocardial involvement in hypertrophic obstructive cardiomyopathy and cardiomyopathy associated with muscular disorders.
CHEST, 68: 1, JULY, 1975
ECG ABNORMAUTIES IN ALCOHOUC CARDIOMYOPATHY 27
REFERENCES
1 Evans W:· The electrocardiogram of alcoholic cardiomyopathy. Br Heart J 21 :445-456, 1959 2 Hollister RM, Goodwin JF: The electrocardiogram in cardiomyopathy. Br Heart J 25:357-374, 1963 3 Banta DH, Estes EH: Electrocardiographic and vectorcardiographic findings in patients with idiopathic myocardial hypertrophy. Am J CardioI14:218-225, 1964 4 Marriott HJL: Electrocardiographic abnonnalities, conduction disorders and arrhythmias in primary myocardial disease. Progr Cardiovasc Dis 7:99-114,1964 5 Hamby RI, Raia F: Electrocardiographic aspects of primary myocardial disease in 60 patients. Am Heart J 76:316-328,1968 6 Stapleton JF, Segal JP, Harvey WP: The electrocardiogram of myocardiopathy. Progr Cardiovasc Dis 13:217239,1970 7 Pinto Lima FX, Spiritus 0, Tranchesi J: Arrhythmias and vectorcardiographic analysis of complete bundle branch block in Chagas disease: A study of 103 autopsied cases. Am Heart J 56:501-509, 1958 8 Manning GW: Cardiac manifestations in Friedreieh's ataxia. Am Heart J 39:799-816, 1950 9 PerlofI JK, Roberts WC, DeLeon AC Jr, et al: The distinctive electrocardiogram of Duehenne's progressive muscular dystrophy. An electrocardiographic-pathologic correlative study. Am J Moo 42:179-188, 1967 10 Bashour IT, FahdulH, Cheng TO: Multifascicular block in cardiomyopathy: Incidence, localization by His bundle study and prognosis. In press 11 Massumi RA, Rios JC, Gooch AS, et al: Primary myocardial disease: Report of fifty cases and review of the subject. Circulation 31: 19-41, 1965 12 Frank S, Braunwald E: Idiopathic hypertrophic subaortic stenosis. Clinical analysis of 126 patients with emphasis on the natural history. Circulation 37 :759-788, 1968
Electrocardiograms of 65 patients with alcoh06c cardiomyopathy seen over a five-year period were reviewed. ST segment and T wave abnonnaUties, left ventricular hypertrophy, biatrial enlargement, left atrial enlargement, premature ventricular contractions, prolonged PR inte"aI, and left anterior hemiblock are the most frequently encountered abaonnaUties. A combination of left ventricular hypertrophy and biatrial enlargement
with or without left anterior hemiblock is most specific. Atrial ftutter or fibrillation, patboJocic Q waves, and bifascicular block are not uncommon fiDdlDp, wblle isolated right atrial or right ventricular abnormaHties, aad isolated posterior hemiblock or right bundle branch block are rare. Electrocanliographic changes are In general similar to those seen in any diffuse cardiomyopathy and reftect biventricular involvement.
The electrocardiographic manifestations of cardiomyopathy have been the subject of several investigations.':" Basically similar abnormalities were found in idiopathic, familial and alcoholic cardiomyopathy.' Few specific myocardial diseases may be associated with high preponderance of a special abnormality such as right bundle branch block in Chagas disease," right axis deviation in Friedreich's ataxia," and a posterior necrosis pattern in Duchenne's muscular dystrophy." In this investigation, we report the electrocardiographic abnormalities in 65 patients with alcoholic cardiomyopathy, an especially conunon disease in our hospital; herein we attempt to establish the general incidence of different electrocardiographic patterns in this homogeneous type of cardiomyopathy.
Washington University Hospital were diagnosed as having cardiomyopathy associated with alcohol abuse. The diagnosis was made on the basis of excessive alcoholic consumption 0 and history, along with clinical, radiologic, and hemodynamic features of diHuse myocardial disease. Patients with diastolic pressure above 100 mm Hg and/or systolic pressure above 150 mm Hg were excluded from this study. Also excluded were those with coronary artery disease and valvular heart disease. The presence and progression of the following electrocardiographic abnormalities were determined from interval tracings averaging six 12-lead electrocardiograms per patient: rhythm disturbances, left atrial enlargement, right atrial enlargement, biatrial enlargement, left ventricular hypertrophy, right ventricular hypertrophy, biventricular hypertrophy, left anterior hemiblock, left posterior hemiblock, left bundle branch block, 6rst degree atrioventricular block, and unde6ned intraventricular conduction defects.
MATERIALS AND METHODS
Between April 1969 and March 1974, 65 patients admitted to the District of Columbia General Hospital and the George °From the Department of Medicine, Division of Cardiology The George Washington University School of Medicine and The George Washington University Medical Division, District of Cohunbia General Hospital, Washington, D.C. 00 Assistant Professor of Medicine (Cardiology), The George Washington University School of Medicine. tFellow in Cardiology, District of Columbia General Hospital. tProfessor of Medicine (Cardiology), The George Washington University School of Medicine; Associate Director, Division of Cardiology, and Director, Cardiac Catheterization Laboratory, The George Washington University Medical Center. Manuscript received July 15, 1974; revision accepted November8. Reprint requests: Dr. Cheng, 2150 Pennsylvania Avenue NW, Washington, D.C. 20037
24 BASHOUR, FAHDUL, CHENG
RESULTS
Our findings are reported in Table 1. Fifty-Six patients were men and nine were women, ages ranging between 21 and 66 years, with an average of 42 years. The average follow-up period was 21.4 months.
Rhythm Disturbance Sinus rhythm was present in 57 patients and eight patients had atrial fibrillation or atrial Hutter. Premature atrial contractions were found in 11 cases; they antedated the development of atrial o Defined
as the repeated drinking of alcoholic beverages to an extent that exceeds customary dietary use or surpasses the social drinking customs of the community. Each patient in our series admitted to regular consumption of at least 4 drinks a day over a period of six years or longer.
CHEST, 68: 1, JULY, 1975
Table I-Incidence 01 Elec'rocardio«raphic AbnormaUde. in 65 Patien,.
ciated with left bundle branch block and in four with right bundle branch block. Left posterior hemiblock was found in three patients, in two of them in association with right bundle branch block. Right bundle branch block was present in six patients; in four it was associated with left anterior hemiblock (Fig I-A) and in two with left posterior hemiblock. Left bundle branch block was found in seven patients (10.8 percent); it was isolated in four and associated with abnormal left axis deviation in three (Fig I-B). Patients with bifascicular block were studied separately with the help of His bundle electrocardiography and are to be reported in another communication. 10 Abnonnally wide QRS complexes atypical for either left or right bundle branch block were present in five patients.
Percent No. of InciPatients dence Rhythm Disturbance:
Premature ventricular con tractions Ventricular tachycardia Premature atrial contractions Atrial fibrillation or flutter
Conduction Disturbance:
1st degree atrioventricular block Left anterior hemiblock Left posterior hemiblock Left bundle branch block Right bundle branch block Intraventricular conduction defect
Atrial Abnormality: Ventricular Abnormality:
24 2 11 8
37 3 17 12.3
22 17 3 7 6
34 26
5
5
10.7 9.2 7.7
Left atrial enlargement Right atrial enlargement Biatrial enlargement
15
23
35
52.2
Pathologic Q Left ventricular hypertrophy Right ventricular hypertrophy Biventricular hypertrophy
3 43 2 3
5 66 3 5
65
100%
Other ST-T changes Abnormalities:
Atrial Abnormalities The most common atrial wave abnormality was a wide and tall P wave in lead 2 with prominent diphasic P wave in lead VI, both consistent with biatrial enlargement (Fig 2). This sign was present in 35 patients (52.2 percent). P waves consistent with left atrial enlargement were found in 15 patients (23 percent) in nine of them in association with left ventricular hypertrophy. In all, atrial ab- . normalities including atrial fibrillation were present in 58 patients (89 percent) .
fibrillation in three patients. Frequent premature ventricular contractions were relatively common, being found in 24 patients (37 percent). Short runs of ventricular tachycardia were documented in two of these patients, one of them having had syncopal attacks. Premature ventricular contractions were generally resistant to antiarrhythmic agents and tended to persist despite effective control of congestive heart failure.
Ventricular Abnormalities Left ventricular hypertrophy was quite common, being found in 43 patients (66 percent), as shown in Figure 2. In all of them the criteria included also ST segment and T waves abnonnalities, although almost all patients were receiving digitalis compounds. Right ventricular hypertrophy was uncommon, being found in only two patients. Three patients had changes consistent with biventricular hypertrophy.
Conduction Disturbance First degree atrioventricular block (PR interval longer than 200 msec ) was present in 22 patients (34 percent). Left anterior hemiblock was present in 17 patients (26 percent); in three it was asso-
Alii .~". I iilil;" F
BIIIIIIIIIIIII FIGURE 1. Two examples of bundle branch block. A. Right bundle branch block is associated with extreme left axis deviation consistent with left anterior hemiblock. B. Left bundle branch block and abnormal left axis deviation are present.
CHEST, 68: 1, JULY, 1975
ECG ABNORMAUTIES IN ALCOHOLIC CARDIOMYOPATHY 25
FIGURE 2. Electrocardiograms of three patients. The first (A) shows left ventricular hypertrophy with P wave abnormality consistent with biatrial enlargement (see text f01' explanation). The second tracing (B) shows the same atrial abnormality in addition to left anterior hemiblock. The third tracing (C) shows prolonged PR interval, left anterior hemiblock, left ventricular hypertrophy, and biatrial enlargement, a combination quite characteristic of cardiomyopathy.
B
Other Abnormalities Variable degrees of ST segment and T wave changes were present in all patients (Table 1); in the majority these were nonspecific, but frequently they were consistent with left ventricular strain or with digitalis effect. Pathologic Q waves were present in three patients who were all below the age of 30 years, and none had history consistent with coronary insufficiency. In one, QS complexes were localized in leads 2, 3 and aVF (Fig 3-A); in the second, in leads VI-V3 (Fig 3-B ); in the third, in leads 1 and aVL. DIscuSSION
Clinical evaluation of primary myocardial disease including electrocardiographic data was reported earlier from our hospital," and other comprehensive reviews of the subject were also reported.':" The purpose of the current report is to add 65 new cases of myocardial disease, all associated with excessive alcoholic intake. While most other reports 2-6.9 included all types of primary myocardial disease, this series deals exclusively with that associated with excessive alcoholic intake, the so-called alcoholic cardiomyopathy. To our knowledge this is the largest series so far published dealing with the electrocardiographic features of this entity. An impressive closeness in the incidence of different electrocardiographic abnormalities is shared by our patients -and those reported by others. A lower incidence of atrial fibrillation was reported by Banta et aI;3 their patients, however, were believed to have idiopathic myocardial hypertrophy and the incidence of alcohol abuse was not mentioned. Our
2& BASHOUR, FAHDUL, CHENG
1
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V1
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:!"
I'
,
V4
V5
I
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V4
V5 V6
FIGURE 3. Pathologic Q waves in cardiomyopathy. Tracing A belongs to a 28-year-old patient; it shows Q waves in leads 2,3 and aVF (inferior necrosis pattern). Tracing B shows QS complexes in VI-V 3 (anterior necrosis pattern). Biatrial enlargement is also seen in both tracings, and left ventricular hypertrophy is present in B.
CHEST, 68: 1, JULY, 1975
findings suggest that, regardless of the etiology of diffuse myocardial disease, electrocardiographic changes are similar, a fact that probably reflects similar hemodynamic alterations resulting from widespread myocardial dysfunction. The frequent bilateral atrial abnormalities suggest involvement of both ventricles with either primary or secondary involvement of the atria. A combination of biatrial enlargement and left ventricular hypertrophy (Fig 2) with or without left anterior hemiblock is quite common and most specific. An interesting finding is the rarity of electrocardiographic criteria for isolated right ventricular hypertrophy, although this may be indirectly inferred from right atrial enlargement. We speculate that, since left ventricular forces are dominant on the normal electrocardiogram, this dominance is likely to be maintained when both ventricles are involved equally. In another report from our institution the localization and the prognosis of bifascicular block in these patients were evaluated by His bundle studies, atrial pacing and clinical followup. 10 We found that, despite the common delay in the His-Purkinje system, prognosis was appreciably better than that found in bifascicular block due to coronary artery disease. In comparison with hypertrophic obstructive cardiomyopathy, 12 conduction defects and atrial abnormalities including atrial fibrillation seem to be more, and pathologic Q waves less, common in alcoholic cardiomyopathy. Finally, it is logical to conclude that alcoholic cardiomyopathy results in electrocardiographic changes similar to those produced by other diffuse types of cardiomyopathy, and different from
changes due to more selective types of myocardial involvement in hypertrophic obstructive cardiomyopathy and cardiomyopathy associated with muscular disorders.
CHEST, 68: 1, JULY, 1975
ECG ABNORMAUTIES IN ALCOHOUC CARDIOMYOPATHY 27
REFERENCES
1 Evans W:· The electrocardiogram of alcoholic cardiomyopathy. Br Heart J 21 :445-456, 1959 2 Hollister RM, Goodwin JF: The electrocardiogram in cardiomyopathy. Br Heart J 25:357-374, 1963 3 Banta DH, Estes EH: Electrocardiographic and vectorcardiographic findings in patients with idiopathic myocardial hypertrophy. Am J CardioI14:218-225, 1964 4 Marriott HJL: Electrocardiographic abnonnalities, conduction disorders and arrhythmias in primary myocardial disease. Progr Cardiovasc Dis 7:99-114,1964 5 Hamby RI, Raia F: Electrocardiographic aspects of primary myocardial disease in 60 patients. Am Heart J 76:316-328,1968 6 Stapleton JF, Segal JP, Harvey WP: The electrocardiogram of myocardiopathy. Progr Cardiovasc Dis 13:217239,1970 7 Pinto Lima FX, Spiritus 0, Tranchesi J: Arrhythmias and vectorcardiographic analysis of complete bundle branch block in Chagas disease: A study of 103 autopsied cases. Am Heart J 56:501-509, 1958 8 Manning GW: Cardiac manifestations in Friedreieh's ataxia. Am Heart J 39:799-816, 1950 9 PerlofI JK, Roberts WC, DeLeon AC Jr, et al: The distinctive electrocardiogram of Duehenne's progressive muscular dystrophy. An electrocardiographic-pathologic correlative study. Am J Moo 42:179-188, 1967 10 Bashour IT, FahdulH, Cheng TO: Multifascicular block in cardiomyopathy: Incidence, localization by His bundle study and prognosis. In press 11 Massumi RA, Rios JC, Gooch AS, et al: Primary myocardial disease: Report of fifty cases and review of the subject. Circulation 31: 19-41, 1965 12 Frank S, Braunwald E: Idiopathic hypertrophic subaortic stenosis. Clinical analysis of 126 patients with emphasis on the natural history. Circulation 37 :759-788, 1968
