Correspondence

Pounding in the Neck in Supraventricular Tachycardia

N Engl J Med 1993; 328:286-287January 28, 1993

Article

To the Editor:

Gursoy et al. (Sept. 10 issue)1 should have defined “pounding in the neck” in their article on its hemodynamic mechanism. Nowhere in their article is an explanation of the apparently subjective sensation given, in spite of the fact that the symptom is the crux of their study. The terms “pounding in the neck” and “neck pounding” are repeatedly used, with modifiers such as “rapid and regular” and “slow, irregular.” Clarification of this apparently distinctive phenomenon might assist its acceptance in reference books in the future.

Charles K. Tashima, M.D.
1213 Hermann Dr., Houston, TX 77004

1 References

1. 1

   Gursoy S, Steurer G, Brugada J, Andries E, Brugada P. The hemodynamic mechanism of pounding in the neck in atrioventricular nodal reentrant tachycardia. N Engl J Med 1992;327:772-774
   Full Text | Web of Science | Medline

To the Editor:

In their interesting article, Gursoy et al. explain the appearance of high pressure peaks in the right atrium during atrioventricular nodal reentrant tachycardia as due to the fusion of A and V waves.

V waves are due to atrial filling through venous return during ventricular systole.1 Using right atrial angiography, the authors nicely demonstrate the backflow of blood from the right atrium to the peripheral veins during right atrial systole, which occurs almost simultaneously with right ventricular systole. So, by definition, there is no V wave, and the pressure peak must be due to right atrial contraction against closed tricuspid valves, possibly augmented by a C wave, because of closure of the tricuspid valve on right ventricular contraction.

Gerjan de Weerd, M.D.
Albert Meyer, M.D.
Freek W.A. Verheugt, M.D.
Free University Hospital, 1081 HV Amsterdam, the Netherlands

1 References

1. 1

   Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 4th ed. Philadelphia: W.B. Saunders, 1992:187.
   

To the Editor:

Gursoy et al. were at a loss to explain why patients with atrioventricular nodal reentrant tachycardia who have large A and V waves experience pounding in the neck but have no such symptoms in the right upper quadrant despite marked reflux into the inferior vena cava.

It is possible that the presence of competent venous valves in the jugular and subclavian venous bulbs is in part responsible for this phenomenon, either indirectly because they reduce venous compliance, or potentially because they cause acute dilation of the bulbs themselves1-3.

Jeffrey Fisher, M.D.
New York Hospital-Cornell Medical Center, New York, NY 10021

3 References

1. 1

   Fisher J, Vaghaiwalla F, Tsitlik J, et al. Determinants and clinical significance of jugular venous valve competence. Circulation 1982;65:188-196
   CrossRef | Web of Science | Medline

2. 2

   Fisher J. Jugular venous valves and physical signs. Chest 1984;85:685-686
   CrossRef | Web of Science | Medline

3. 3

   Fisher J. The rediscovery of intrathoracic venous valves. Cardiovasc Rev Rep 1986;7:617-621
   

Author/Editor Response

The authors reply:

To the Editor: Neck palpitations or pounding was defined as a feeling of rapid regular beating in the area of the jugular veins, with or without a feeling of rapid regular beating in the precordial area. Venous valves may indeed have a role in the feeling of neck pounding during intranodal tachycardia. We agree with Dr. de Weerd and coworkers that reflux is (at least partially) caused by simultaneous atrial and ventricular contraction during intranodal tachycardia. How to name the different deflections on the tracing for jugular or right atrial pressure during the arrhythmia is a matter of semantics.

Sinan Gursoy, M.D.
Erik Andries, M.D.
Pedro Brugada, M.D.
Onze Lieve Vrouw Hospital, B9300 Aalst, Belgium

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