Prolonged electrocardiographic (Holter) recording was performed to analyze terminal electrical events in 23 hospitalized adults who died without apparent cardiac disease. Most patients showed a gradual slowing of heart rate with shifting of cardiac pacemaker downward from the sinus node or atria to the atrioventricular junction and ventricles, resulting in cardiac asystole. Dominant bradyarrhythmia was more common than ventricular tachyarrhythmia (83 vs 17%). Agonal ST-segment elevation was not uncommon (26%). These terminal electrical events became manifest from 1 to 450 minutes (mean 62) before cessation of cardiac electrical activity. Forty-eight percent of the patients continued to show deteriorating sinus or atrial activity up to the last moment. The mechanism of bradycardiac asystole in patients with no apparent cardiac disease may be attributed to generalized anoxic and toxic depression of the sinus node and subsidiary pacemakers, together with neurogenic suppression of these structures.
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