Background Although electrical alternans (alternating amplitudefrom beat to beat on the electrocardiogram) has been associatedwith ventricular arrhythmias in many clinical settings, itsphysiologic importance and prognostic implications remain unknown.
Methods To test the hypothesis that electrical alternans isa marker of vulnerability to ventricular arrhythmias, we developeda technique to detect subtle alternation in the morphologicfeatures of the electrocardiogram (which would not be detectableby visual inspection of the electrocardiogram). In a group of83 patients referred for diagnostic electrophysiologic testing,we prospectively examined whether levels of alternans predictedvulnerability to arrhythmias as defined by the outcome of electrophysiologictesting and arrhythmia-free survival.
Results Sustained ventricular arrhythmias were induced duringelectrophysiologic testing in 32 of the patients (39 percent).In this group, low-level electrical alternans (a beat-to-beatchange in amplitude of <15 microV) was detected over a broadrange of physiologic heart rates (from 95 to 150 beats per minute)and primarily involved the ST segment and the T wave (i.e.,the phase of repolarization). Alternans during repolarizationwas a significant and independent predictor of inducible arrhythmiason electrophysiologic testing (sensitivity, 81 percent; specificity,84 percent; relative risk, 5.2). Of 66 patients followed forup to 20 months, 13 had arrhythmic events. Alternans affectingthe T wave and inducibility of ventricular arrhythmias weresignificant and essentially equivalent predictors of survivalwithout arrhythmia (P<0.001). Actuarial survival withoutarrhythmia at 20 months was significantly lower among the patientswith T-wave alternans (19 percent) than among the patients withoutT-wave alternans (94 percent).
Conclusions Electrical alternans affecting the ST segment andT wave is common among patients at increased risk for ventriculararrhythmias. Subtle electrical alternans on the electrocardiogrammay serve as a noninvasive marker of vulnerability to ventriculararrhythmias.
Source Information
From the Cardiac Unit, Massachusetts General Hospital, Boston (D.S.R., H.G., J.N.R.); the Harvard University-Massachusetts Institute of Technology Division of Health Sciences and Technology, Cambridge, Mass. (D.S.R., L.E.J., J.M.S., R.J.C.); and the Departments of Medicine and Biomedical Engineering, Case Western Reserve University, Cleveland (D.S.R.). Presented in part as the Samuel A. Levine Young Investigator Award presentation to the American Heart Association, Anaheim, Calif., Nov. 12, 1991.
Address reprint requests to Dr. Rosenbaum at the Department of Biomedical Engineering, Case Western Reserve University, Wickenden Bldg., Rm. 504, Cleveland, OH 44106.
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