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Stokes-Adams’ Attacks

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Insights into Electrocardiograms with MCQs

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Abstract

Transient loss of consciousness due to prolonged atrioventricular asystole is called Stoke-Adams’ attack. Several rhythm disorders can produce this situation. Electrocardiogram can give some impression about the risk of such episodes. Various rhythm disorders that can be associated with such episodes are discussed with representative electrocardiograms. Limitations of electrocardiogram in predicting occurrence of such episodes are also discussed. Electrocardiogram recorded after an episode of Stokes-Adams’ attack usually shows some classical findings that can give a clue to the possibility of Stokes-Adams’ attack as a cause of preceding transient loss of consciousness. All these issues are discussed with representative electrocardiograms. Summary and MCQs at the end of the chapter help in quick revision and self-assessment.

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Reference

  1. Schamroth L. Atrioventricular (AV) block. In: Schamroth C, editor. An introduction to electrocardiography. Blackwell Science: New Delhi; 1988. p. 375–85.

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Author information

Authors and Affiliations

  1. Ex Senior professor and head of the department of cardiology, Jawaharlal Nehru Medical College, Ajmer, India

    Sitaram Mittal

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  1. Sitaram Mittal
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Appendices

Summary

  • Stokes-Adams’ attacks are episodes of syncope due to transient ventricular asystole, ventricular flutter, or fibrillation.

  • In the setting of atrioventricular block, Stokes-Adams’ attacks usually occur during transition from incomplete to complete atrioventricular block. Attacks are uncommon once the complete atrioventricular block has been stable for a month or more.

  • Following Stokes-Adams’ attacks due to transient atrioventricular block, transient ventricular flutter, or fibrillation, an electrocardiogram may be deceptively normal. In the setting of recent onset of complete atrioventricular block, ECG may show large, broad, and inverted T waves with prolonged QT interval.

  • In the setting of complete atrioventricular block, Stokes-Adams’ attacks may be due to tachyarrhythmias like polymorphic VT, torsades de pointes, or ventricular fibrillation. These tachyarrhythmias may not be preceded by ventricular ectopics.

  • Long sudden sinus pause without an escape focus can also produce Stokes-Adams attack.

  • In the setting of acute anterior infarction, Stokes-Adams’ attacks may be sudden and may not be preceded by first-degree or second-degree atrioventricular block.

  • In the setting of complete atrioventricular block, the presence of intermittent capture beat or retrograde ventriculoatrial conduction suggests a lower risk of Stokes-Adams’ attack.

  • In the setting of complete atrioventricular block, risk of Stokes-Adams’ attacks depends on the site of the escape rhythm. Risk progressively increases as the escape focus shifts distally from the atrioventricular node to the Purkinje network. More peripheral is the pacemaker, the slower is the rate and higher is the risk of Stokes-Adams’ attack.

  • If the escape focus is unstable and intermittently shifts the site, it also increases the risk of Stokes-Adams’ attack.

  • Atrioventricular dissociation does not produce Stokes-Adams’ attacks.

MCQs

Q1. Electrocardiographic findings suggestive of a preceding Stokes-Adams attack include:

  1. (a)

    Complete atrioventricular block

  2. (b)

    Prolonged QTc interval

  3. (c)

    Large, broad and inverted T waves

  4. (d)

    All

Q2. During atrioventricular block, Stokes-Adams’ attacks can occur:

  1. (a)

    When second-degree atrioventricular block suddenly changes to complete atrioventricular block

  2. (b)

    When there is paroxysm of ventricular flutter

  3. (c)

    When there is slowing of ventricular escape rhythm

  4. (d)

    All

Q3. Stokes-Adams’ attacks must always be preceded by:

  1. (a)

    First-degree atrioventricular block

  2. (b)

    Second-degree atrioventricular block

  3. (c)

    Third-degree atrioventricular block

  4. (d)

    None

Q4. Which block in most susceptible for Stokes-Adams’ attacks?

  1. (a)

    Interatrial block

  2. (b)

    Block at the level of the atrioventricular node

  3. (c)

    Intra-His block

  4. (d)

    Infra-His block

Q5. Stokes-Adams’ attack can occur when:

  1. (a)

    Sinus rate is less than 50/minute

  2. (b)

    There is atrial fibrillation with a ventricular rate of 180/minute

  3. (c)

    There is paroxysm of ventricular flutter

  4. (d)

    There is transient ventricular fibrillation

Q6. Stokes-Adams’ attacks are more likely to occur in:

  1. (a)

    Recent onset of complete atrioventricular block

  2. (b)

    Chronic complete atrioventricular block

  3. (c)

    Mobitz type I, second-degree atrioventricular block

  4. (d)

    All

Q7. Broad, inverted T waves with prolongation of QT interval are seen:

  1. (a)

    In subarachnoid hemorrhage

  2. (b)

    In cerebral hemorrhage

  3. (c)

    Following Stokes-Adams’ attacks

  4. (d)

    All

Q8. Stokes-Adams’ attacks are likely to occur in:

  1. (a)

    Mobitz type II second-degree atrioventricular block

  2. (b)

    Presence of Wenckebach phenomenon

  3. (c)

    Atrial fibrillation with slow ventricular rate

  4. (d)

    Atrial fibrillation with fast ventricular rate

Q9. Stokes-Adams’ attacks are likely to occur in:

  1. (a)

    Complete atrioventricular block with narrow QRS at a rate of 50/minute

  2. (b)

    Complete atrioventricular block with broad QRS at a rate of 35/minute

  3. (c)

    Complete atrioventricular block with unstable ventricular focus

  4. (d)

    All

Q10. Stokes-Adams’ attacks are more likely to occur in:

  1. (a)

    Congenital complete atrioventricular block

  2. (b)

    Complete atrioventricular block in the setting of acute inferior myocardial infarction

  3. (c)

    Complete atrioventricular block in the setting of acute anterior myocardial infarction

  4. (d)

    Ventricular bigeminy

Q11. Stokes-Adams’ attack is more likely to occur in:

  1. (a)

    Junctional tachycardia

  2. (b)

    Ventricular tachycardia

  3. (c)

    Atrial fibrillation with antegrade conduction over atrioventricular node

  4. (d)

    None

Q12. Stokes-Adams’ attacks can occur in:

  1. (a)

    Sick sinus syndrome

  2. (b)

    Concealed accessory pathway

  3. (c)

    Ventricular trigeminy

  4. (d)

    All

Q13. Stokes-Adams’ attacks are more likely to occur in the setting of:

  1. (a)

    Atrioventricular V dissociation

  2. (b)

    Long sinus pause with slow escape rhythm

  3. (c)

    Complete atrioventricular block with intermittent narrow QRS (capture beats)

  4. (d)

    Complete atrioventricular block with intermittent retrograde (ventriculoatrial) conduction to atria

Q14. Stokes-Adams’ attacks are most likely to occur in a complete atrioventricular block with the escape rhythm arising from:

  1. (a)

    The atrioventricular node

  2. (b)

    The His bundle

  3. (c)

    The bundle branches

  4. (d)

    The Purkinje network

Q15. Stokes-Adams’ attacks in the setting of acute anterior infarction are always preceded by:

  1. (a)

    First-degree atrioventricular block

  2. (b)

    Wenckebach phenomenon

  3. (c)

    Mobitz type II second-degree atrioventricular block

  4. (d)

    None

Q16. Following an episode of Stokes-Adams’ attack, the ECG may show:

  1. (a)

    No abnormality

  2. (b)

    Broad inverted T wave

  3. (c)

    Myocardial infarction

  4. (d)

    Any of above

Answers

(1) d; (2) d; (3) d; (4) d; (5) c, d; (6) a; (7) d; (8) a; (9) b, c; (10) c; (11) d; (12) a; (13) b; (14) d; (15) d; (16) d

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Mittal, S. (2023). Stokes-Adams’ Attacks. In: Insights into Electrocardiograms with MCQs. Springer, Singapore. https://doi.org/10.1007/978-981-99-0127-2_13

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  • DOI: https://doi.org/10.1007/978-981-99-0127-2_13

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  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-99-0126-5

  • Online ISBN: 978-981-99-0127-2

  • eBook Packages: MedicineMedicine (R0)

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