The purpose of this study was to evaluate the need for permanent pacing in patients who have survived the effects of anterior myocardial infarction with complete heart block and have returned to sinus rhythm but who are left with impairment of intraventricular conduction. We reviewed. All had been referred with recent anterior myocardial infarction complicated by the development of complete heart block. It was not known whether there was pre-existing fascicular block before infarction. In 2 patients (Cases 3 and 6) a narrow QRS in the presence of complete heart block suggested proximal atrioventricular block. In all other patients the level of the block was considered to be distal in site because of the slow rate of the escape pacemaker and a QRS width of at least 0 12 s. All patients needed temporary pacing.The diagnosis of acute myocardial infarction was established by a typical history accompanied by characteristic enzyme rises and the development of pathological Q waves accompanied by ST segment and T wave changes in the anterior chest leads. Bundle-branch block was defined according to the criteria of Goldman (1967) and the criteria for hemiblock were those of Rosenbaum (1970). Partial bilateral bundle-branch block was defined as right bundle-branch block and left anterior hemiblock or right bundle-branch block and left posterior hemiblock.The usual hospital stay was at least 3 weeks and follow-up observations were obtained in all patients. His bundle electrograms were recorded in 8 patients after return to sinus rhythm, using the technique described by Scherlag et al. (1969). 186

A woman with proven systemic lupus erythematosus is described, in whom the aortic valve was also involved. She was treated with corticosteroids. The effect of the aort&c valve involvement progressed and necessitated replacement by Starr-Edwards Case reportA 38-year-old business woman first presented in I965 with joint pains in her hands and wrists of 4 years' duration. She was normotensive. Her ESR was 30 mm/hr (Westergren) and tests for rheumatoid factor were negative. In I968 a soft early diastolic murmur was first heard; electrocardiogram and chest x-ray were normal. There was no history of rheumatic fever and the Wassermann reaction was negative. In I969 she had an episode of leftsided pleurisy. In February I97I she was admitted to Westminster Hospital because of a low grade fever, night sweats, and dyspnoea. Her blood pressure was 240/ 30 mmHg; the heart murmur was louder. Chest x-ray showed some cardiac enlargement and there was electrocardiographic evidence of pericarditis. The ESR was 83 mm/hr (Westergren), blood cultures were negative,