Relation of T-wave alternans to regional left ventricular dysfunction and eccentric hypertrophy secondary to coronary heart disease.

Left ventricular (LV) hypertrophy and structural disease are associated with exaggerated repolarization dispersion and risk for cardiac arrest. We hypothesized that T-wave alternans (TWA) from the electrocardiogram, reflecting proarrhythmic repolarization dispersion, would increase with extent of eccentric LV hypertrophy and vary spatially with the distribution of myocardial scar. We studied 28 patients with coronary disease, systolic dysfunction, and nonsustained ventricular tachycardia. On echocardiography, 21 patients had wall motion abnormalities and 20 had LV hypertrophy (mass index > or =100 g/m(2)). TWA magnitude (voltage of alternation), which was computed spectrally during ventricular stimulation, varied linearly with LV mass index (p = 0.003). Spatially, positive TWA (magnitude > or =1.9 microV) in orthogonal electrocardiographic axes overlaid scar or wall motion abnormalities in corresponding echocardiographic segments (p <0.05 in x and y axes). After a follow-up of 35 +/- 13 months, positive TWA predicted the combined end point of death or sustained ventricular arrhythmias in all patients (p = 0.025), with a trend for those with echocardiographic LV hypertrophy (p = 0.058). In conclusion, in patients with systolic dysfunction due to coronary artery disease, TWA may indicate arrhythmic contributions from regional myocardial scar and eccentric LV hypertrophy.

[1]  M R Gold,et al.  A comparison of T-wave alternans, signal averaged electrocardiography and programmed ventricular stimulation for arrhythmia risk stratification. , 2000, Journal of the American College of Cardiology.

[2]  Michael R Gold,et al.  Enhanced Detection of Arrhythmia Vulnerability Using T Wave Alternans, Left Ventricular Ejection Fraction, and Programmed Ventricular Stimulation: , 2004, Journal of cardiovascular electrophysiology.

[3]  E. Keung,et al.  Non‐uniform Electrophysiological Properties and Electrotonic Interaction in Hypertrophied Rat Myocardium , 1981, Circulation research.

[4]  J. Johnston,et al.  Left ventricular hypertrophy in hypertensive patients is associated with abnormal rate adaptation of QT interval. , 1997, Journal of the American College of Cardiology.

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

[6]  P. Kowey,et al.  Regression of left ventricular hypertrophy with captopril restores normal ventricular action potential duration, dispersion of refractoriness, and vulnerability to inducible ventricular fibrillation. , 1997, Circulation.

[7]  F. Messerli.  Hypertension and sudden cardiac death. , 1999, American journal of hypertension.

[8]  J. Ruskin,et al.  Electrical alternans and vulnerability to ventricular arrhythmias. , 1994, The New England journal of medicine.

[9]  M. Hennersdorf,et al.  T Wave Alternans and Ventricular Arrhythmias in Arterial Hypertension , 2001, Hypertension.

[10]  S. Hohnloser,et al.  Quantitative Assessment of Microvolt T‐Wave Alternans in Patients with Congestive Heart Failure , 2005, Journal of cardiovascular electrophysiology.

[11]  H. E. Keurs,et al.  Reverse Excitation‐Contraction Coupling: Ca2+ Ions as Initiators of Arrhythmias , 2001, Journal of cardiovascular electrophysiology.

[12]  C. Specchia,et al.  The worsening of left ventricular hypertrophy is the strongest predictor of sudden cardiac death in haemodialysis patients: a 10 year survey. , 2004, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[13]  M. Josephson,et al.  Relation of Ejection Fraction and Inducible Ventricular Tachycardia to Mode of Death in Patients With Coronary Artery Disease: An Analysis of Patients Enrolled in the Multicenter Unsustained Tachycardia Trial , 2002, Circulation.

[14]  M. Josephson,et al.  Electrocardiographic Predictors of Arrhythmic Death and Total Mortality in the Multicenter Unsustained Tachycardia Trial , 2004, Circulation.

[15]  J. Hartikainen,et al.  Microvolt T‐Wave Alternans During Exercise and Pacing in Patients with Acute Myocardial Infarction , 2005, Pacing and clinical electrophysiology : PACE.

[16]  Sanjiv M. Narayan,et al.  Exploiting rate-related hysteresis in repolarization alternans to improve risk stratification for ventricular tachycardia. , 2000, Journal of the American College of Cardiology.

[17]  J Thomas Bigger,et al.  Microvolt T-Wave Alternans Distinguishes Between Patients Likely and Patients Not Likely to Benefit From Implanted Cardiac Defibrillator Therapy: A Solution to the Multicenter Automatic Defibrillator Implantation Trial (MADIT) II Conundrum , 2004, Circulation.

[18]  J. Bigger,et al.  Ambulatory Electrocardiogram‐Based Tracking of T Wave Alternans in Postmyocardial Infarction Patients to Assess Risk of Cardiac Arrest or Arrhythmic Death , 2003, Journal of cardiovascular electrophysiology.

[19]  B. Lindsay,et al.  T-wave alternans phase following ventricular extrasystoles predicts arrhythmia-free survival. , 2005, Heart rhythm.

[20]  David S. Rosenbaum,et al.  Role of Calcium Cycling Versus Restitution in the Mechanism of Repolarization Alternans , 2004, Circulation research.

[21]  S. Priori,et al.  Early afterdepolarizations induced in vivo by reperfusion of ischemic myocardium. A possible mechanism for reperfusion arrhythmias. , 1990, Circulation.

[22]  Peter J. Schwartz,et al.  Clinical aspects of ventricular repolarization , 1989 .

[23]  K. Lee,et al.  Differences in inducibility and prognosis of in-hospital versus out-of-hospital identified nonsustained ventricular tachycardia in patients with coronary artery disease: clinical and trial design implications. , 2001, Journal of the American College of Cardiology.

[24]  B. Lindsay,et al.  Demonstration of the proarrhythmic preconditioning of single premature extrastimuli by use of the magnitude, phase, and distribution of repolarization alternans. , 1999, Circulation.

[25]  D. Rosenbaum,et al.  Role of Structural Barriers in the Mechanism of Alternans-Induced Reentry , 2000, Circulation research.

[26]  Y. Kagaya,et al.  Microvolt T Wave Alternans in Human Cardiac Hypertrophy: Electrical Instability and Abnormal Myocardial Arrangement , 2001, Journal of cardiovascular electrophysiology.