Co-occurrence and phase relationship between alternans of the R wave amplitude (RWAA) and of the T wave (TWA) in ECGs

Alternans of the T wave in ECG (TWA) has high negative but poor positive predictive value in the prediction of ventricular arrhythmia. Alternans of repolarization duration, i.e. of action potential duration (APD), causes TWA. Prior studies from our group showed that alternans of the maximum rate of depolarization also occurs when APD alternans occurs and the relationship between these two has the potential to affect formation of spatial discord, which may be more arrhythmogenic. Therefore, exploration of the co-occurrence of the alternans of depolarization and repolarization has the potential to improve the prediction. In the present study, we used a mathematical model to show that depolarization alternans appears as alternating amplitude of the R wave in the ECG. We also investigated the link between changes in R wave amplitude and TWA. Results from clinical grade ECGs available in the PhysioNet database show that amplitude of the R wave can change as predicted by our experimental results and the mathematical model. Using TWA as the marker of repolarization alternans and R wave amplitude alternans (RWAA) as the marker of depolarization alternans, we investigated the phase relation between them and observed that, similar to previous results from animals, the phase relation between the two can spontaneously change. That is, alternans of depolarization does co-occur with TWA and the phase relationship between the two is not invariant. These results support further investigation of the use of RWAA as a complementary method to TWA to improve positive predictive value for prediction of ventricular arrhythmia.

[1]  G.B. Moody,et al.  The impact of the MIT-BIH Arrhythmia Database , 2001, IEEE Engineering in Medicine and Biology Magazine.

[2]  A. El-Menyar,et al.  T-wave alternans and sudden cardiac death. , 2008, Critical pathways in cardiology.

[3]  Abhijit Patwardhan,et al.  Phase Relationship between Alternans of Early and Late Phases of Ventricular Action Potentials , 2012, Front. Physio..

[4]  J. Spear,et al.  A comparison of alternation in myocardial action potentials and contractility. , 1971, The American journal of physiology.

[5]  Supernormal Conduction and Suppression of Spatially Discordant Alternans of Cardiac Action Potentials , 2016, Front. Physiol..

[6]  J. A. Gomes,et al.  Microvolt T-wave alternans for the risk stratification of ventricular tachyarrhythmic events: a meta-analysis. , 2005, Journal of the American College of Cardiology.

[7]  P. Wolf,et al.  Heart disease and stroke statistics--2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. , 2006, Circulation.

[8]  Vivek Y. Reddy,et al.  A Novel Lead Configuration for Optimal Spatio-Temporal Detection of Intracardiac Repolarization Alternans , 2011, Circulation. Arrhythmia and electrophysiology.

[9]  Siqi Wang.  NONINVASIVE ASSESSMENT AND MODELING OF DIABETIC CARDIOVASCULAR AUTONOMIC NEUROPATHY , 2012 .

[10]  S. Narayan.  T-wave alternans and the susceptibility to ventricular arrhythmias. , 2006, Journal of the American College of Cardiology.

[11]  Flavio H Fenton,et al.  Mechanism for Amplitude Alternans in Electrocardiograms and the Initiation of Spatiotemporal Chaos. , 2017, Physical review letters.

[12]  S. Hohnloser,et al.  Predictive value of T-wave alternans for arrhythmic events in patients with congestive heart failure , 2000, The Lancet.

[13]  Kapil Kumar,et al.  Basis for sudden cardiac death prediction by T-wave alternans from an integrative physiology perspective. , 2009, Heart rhythm.

[14]  G. Moody,et al.  The Physionet/Computers in Cardiology challenge 2008: T-wave alternans , 2008, 2008 Computers in Cardiology.

[15]  K. Prasad,et al.  Electrophysiologic effects of propranolol on the human heart. , 1978, Japanese heart journal.

[16]  Willis J. Tompkins,et al.  A Real-Time QRS Detection Algorithm , 1985, IEEE Transactions on Biomedical Engineering.

[17]  Abhijit Patwardhan,et al.  Phase Relation between Depolarization and Repolarization Alternans in ECG* , 2018, 2018 40th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC).

[18]  Jeffrey M. Hausdorff,et al.  Physionet: Components of a New Research Resource for Complex Physiologic Signals". Circu-lation Vol , 2000 .

[19]  Michela Masè,et al.  Myocardial Fibrosis Assessment by LGE Is a Powerful Predictor of Ventricular Tachyarrhythmias in Ischemic and Nonischemic LV Dysfunction: A Meta-Analysis. , 2016, JACC. Cardiovascular imaging.

[20]  P. Gillette,et al.  QRS prolongation is associated with inducible ventricular tachycardia after repair of tetralogy of Fallot. , 1997, The American journal of cardiology.

[21]  R. Mehra.  Global public health problem of sudden cardiac death. , 2007, Journal of electrocardiology.

[22]  J J Heger,et al.  Sudden cardiac death. , 1998, Circulation.

[23]  Takanori Ikeda,et al.  Predictive value of microvolt T-wave alternans for sudden cardiac death in patients with preserved cardiac function after acute myocardial infarction: results of a collaborative cohort study. , 2006, Journal of the American College of Cardiology.

[24]  A. Garfinkel,et al.  Mechanisms of Discordant Alternans and Induction of Reentry in Simulated Cardiac Tissue , 2000, Circulation.

[25]  Michela Masè,et al.  Heart Rate Turbulence Is a Powerful Predictor of Cardiac Death and Ventricular Arrhythmias in Postmyocardial Infarction and Heart Failure Patients: A Systematic Review and Meta-Analysis , 2016, Circulation. Arrhythmia and electrophysiology.