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Nearing BD, Fialho GL, Waks JW, Maher TR, Clarke JR, Shepherd AJ, D'Avila A, Verrier RL. P-wave alternans rebound following pulmonary vein isolation predicts atrial arrhythmia recurrence. J Cardiovasc Electrophysiol 2024; 35:1360-1367. [PMID: 38715310 DOI: 10.1111/jce.16291] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/27/2024] [Accepted: 04/16/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Numerous P-wave indices have been explored as biomarkers to assess atrial fibrillation (AF) risk and the impact of therapy with variable success. OBJECTIVE We investigated the utility of P-wave alternans (PWA) to track the effects of pulmonary vein isolation (PVI) and to predict atrial arrhythmia recurrence. METHODS This medical records study included patients who underwent PVI for AF ablation at our institution, along with 20 control subjects without AF or overt cardiovascular disease. PWA was assessed using novel artificial intelligence-enabled modified moving average (AI-MMA) algorithms. PWA was monitored from the 12-lead ECG at ~1 h before and ~16 h after PVI (n = 45) and at the 4- to 17-week clinically indicated follow-up visit (n = 30). The arrhythmia follow-up period was 955 ± 112 days. RESULTS PVI acutely reduced PWA by 48%-63% (p < .05) to control ranges in leads II, III, aVF, the leads with the greatest sensitivity in monitoring PWA. Pre-ablation PWA was ~6 µV and decreased to ~3 µV following ablation. Patients who exhibited a rebound in PWA to pre-ablation levels at 4- to 17-week follow-up (p < .01) experienced recurrent atrial arrhythmias, whereas patients whose PWA remained reduced (p = .85) did not, resulting in a significant difference (p < .001) at follow-up. The AUC for PWA's prediction of first recurrence of atrial arrhythmia was 0.81 (p < .01) with 88% sensitivity and 82% specificity. Kaplan-Meier analysis estimated atrial arrhythmia-free survival (p < .01) with an adjusted hazard ratio of 3.4 (95% CI: 1.47-5.24, p < .02). CONCLUSION A rebound in PWA to pre-ablation levels detected by AI-MMA in the 12-lead ECG at standard clinical follow-up predicts atrial arrhythmia recurrence.
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Affiliation(s)
- Bruce D Nearing
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Jonathan W Waks
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy R Maher
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - John-Ross Clarke
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alyssa J Shepherd
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andre D'Avila
- Federal University of Santa Catarina, Florianopolis, Brazil
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard L Verrier
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Lauretti C, Antonio GL, Fernandes AE, Stocco FG, Girardi ACC, Verrier RL, Caramelli B. Empagliflozin's role in reducing ventricular repolarization heterogeneity: insights into cardiovascular mortality decline from the EMPATHY-HEART trial. Cardiovasc Diabetol 2024; 23:221. [PMID: 38926835 PMCID: PMC11210164 DOI: 10.1186/s12933-024-02311-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/16/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND The incidence of myocardial infarction (MI) and sudden cardiac death (SCD) is significantly higher in individuals with Type 2 Diabetes Mellitus (T2DM) than in the general population. Strategies for the prevention of fatal arrhythmias are often insufficient, highlighting the need for additional non-invasive diagnostic tools. The T-wave heterogeneity (TWH) index measures variations in ventricular repolarization and has emerged as a promising predictor for severe ventricular arrhythmias. Although the EMPA-REG trial reported reduced cardiovascular mortality with empagliflozin, the underlying mechanisms remain unclear. This study investigates the potential of empagliflozin in mitigating cardiac electrical instability in patients with T2DM and coronary heart disease (CHD) by examining changes in TWH. METHODS Participants were adult outpatients with T2DM and CHD who exhibited TWH > 80 µV at baseline. They received a 25 mg daily dose of empagliflozin and were evaluated clinically including electrocardiogram (ECG) measurements at baseline and after 4 weeks. TWH was computed from leads V4, V5, and V6 using a validated technique. The primary study outcome was a significant (p < 0.05) change in TWH following empagliflozin administration. RESULTS An initial review of 6,000 medical records pinpointed 800 patients for TWH evaluation. Of these, 412 exhibited TWH above 80 µV, with 97 completing clinical assessments and 90 meeting the criteria for high cardiovascular risk enrollment. Empagliflozin adherence exceeded 80%, resulting in notable reductions in blood pressure without affecting heart rate. Side effects were generally mild, with 13.3% experiencing Level 1 hypoglycemia, alongside infrequent urinary and genital infections. The treatment consistently reduced mean TWH from 116 to 103 µV (p = 0.01). CONCLUSIONS The EMPATHY-HEART trial preliminarily suggests that empagliflozin decreases heterogeneity in ventricular repolarization among patients with T2DM and CHD. This reduction in TWH may provide insight into the mechanism behind the decreased cardiovascular mortality observed in previous trials, potentially offering a therapeutic pathway to mitigate the risk of severe arrhythmias in this population. TRIAL REGISTRATION NCT: 04117763.
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Affiliation(s)
- Cristiane Lauretti
- Interdisciplinary Medicine Unit in Cardiology, Heart Institute of the Clinical Hospital of the Medical School of the University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44- Anexo II, Sao Paulo, 05403000, SP, Brazil
| | - Graziella L Antonio
- Interdisciplinary Medicine Unit in Cardiology, Heart Institute of the Clinical Hospital of the Medical School of the University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44- Anexo II, Sao Paulo, 05403000, SP, Brazil
| | - Ariana E Fernandes
- Interdisciplinary Medicine Unit in Cardiology, Heart Institute of the Clinical Hospital of the Medical School of the University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44- Anexo II, Sao Paulo, 05403000, SP, Brazil
| | - Fernando G Stocco
- Interdisciplinary Medicine Unit in Cardiology, Heart Institute of the Clinical Hospital of the Medical School of the University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44- Anexo II, Sao Paulo, 05403000, SP, Brazil
| | - Adriana C C Girardi
- Medical School Laboratory of Genetics and Molecular Cardiology , Heart Institute of the Clinical Hospital University of Sao Paulo , Sao Paulo, 05403000, Brazil, SP
| | - Richard L Verrier
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA, 02215, United States of America
| | - Bruno Caramelli
- Interdisciplinary Medicine Unit in Cardiology, Heart Institute of the Clinical Hospital of the Medical School of the University of Sao Paulo, Av. Dr. Enéas Carvalho de Aguiar, 44- Anexo II, Sao Paulo, 05403000, SP, Brazil.
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Fialho GL, Pang TD, Kong WY, Tran AP, Yu CG, Rodriguez ID, Nearing BD, Waks JW, Maher TR, Clarke JR, Shepherd A, D'Avila A, Schachter SC, Verrier RL. Individuals with chronic epilepsy have elevated P-wave heterogeneity comparable to patients with atrial fibrillation. Epilepsia 2023; 64:2361-2372. [PMID: 37329175 DOI: 10.1111/epi.17686] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Identification of epilepsy patients with elevated risk for atrial fibrillation (AF) is critical given the heightened morbidity and premature mortality associated with this arrhythmia. Epilepsy is a worldwide health problem affecting nearly 3.4 million people in the United States alone. The potential for increased risk for AF in patients with epilepsy is not well appreciated, despite recent evidence from a national survey of 1.4 million hospitalizations indicating that AF is the most common arrhythmia in people with epilepsy. METHODS We analyzed inter-lead heterogeneity of P-wave morphology, a marker reflecting arrhythmogenic nonuniformities of activation/conduction in atrial tissue. The study groups consisted of 96 patients with epilepsy and 44 consecutive patients with AF in sinus rhythm before clinically indicated ablation. Individuals without cardiovascular or neurological conditions (n = 77) were also assessed. We calculated P-wave heterogeneity (PWH) by second central moment analysis of simultaneous beats from leads II, III, and aVR ("atrial dedicated leads") from standard 12-lead electrocardiography (ECG) recordings from admission day to the epilepsy monitoring unit (EMU). RESULTS Female patients composed 62.5%, 59.6%, and 57.1% of the epilepsy, AF, and control subjects, respectively. The AF cohort was older (66 ± 1.1 years) than the epilepsy group (44 ± 1.8 years, p < .001). The level of PWH was greater in the epilepsy group than in the control group (67 ± 2.6 vs. 57 ± 2.5 μV, p = .046) and reached levels observed in AF patients (67 ± 2.6 vs. 68 ± 4.9 μV, p = .99). In multiple linear regression analysis, PWH levels in individuals with epilepsy were mainly correlated with the PR interval and could be related to sympathetic tone. Epilepsy remained associated with PWH after adjustments for cardiac risk factors, age, and sex. SIGNIFICANCE Patients with chronic epilepsy have increased PWH comparable to levels observed in patients with AF, while being ~20 years younger, suggesting an acceleration in structural change and/or cardiac electrical instability. These observations are consistent with emerging evidence of an "epileptic heart" condition.
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Affiliation(s)
- Guilherme L Fialho
- Federal University of Santa Catarina, Florianopolis, Brazil
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Trudy D Pang
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Wan Yee Kong
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Anthony P Tran
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Calvin G Yu
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Ivo D Rodriguez
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Bruce D Nearing
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Jonathan W Waks
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Timothy R Maher
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - John-Ross Clarke
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Alyssa Shepherd
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Andre D'Avila
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Steven C Schachter
- Departments of Neurology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Richard L Verrier
- Departments of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
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Duca ȘT, Roca M, Costache AD, Chetran A, Afrăsânie I, Miftode RȘ, Tudorancea I, Matei I, Ciorap RG, Mitu O, Bădescu MC, Iliescu-Halitchi D, Halițchi-Iliescu CO, Mitu F, Lionte C, Costache II. T-Wave Analysis on the 24 h Holter ECG Monitoring as a Predictive Assessment of Major Adverse Cardiovascular Events in Patients with Myocardial Infarction: A Literature Review and Future Perspectives. Life (Basel) 2023; 13:life13051155. [PMID: 37240799 DOI: 10.3390/life13051155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Myocardial ischemia is a pathophysiological state characterized by inadequate perfusion of the myocardium, resulting in an imbalance between myocardial oxygen demand and supply. It is most commonly caused by coronary artery disease, in which atherosclerotic plaques lead to luminal narrowing and reduced blood flow to the heart. Myocardial ischemia can manifest as angina pectoris or silent myocardial ischemia and can progress to myocardial infarction or heart failure if left untreated. Diagnosis of myocardial ischemia typically involves a combination of clinical evaluation, electrocardiography and imaging studies. Electrocardiographic parameters, as assessed by 24 h Holter ECG monitoring, can predict the occurrence of major adverse cardiovascular events in patients with myocardial ischemia, independent of other risk factors. The T-waves in patients with myocardial ischemia have prognostic value for predicting major adverse cardiovascular events, and their electrophysiological heterogeneity can be visualized using various techniques. Combining the electrocardiographic findings with the assessment of myocardial substrate may offer a better picture of the factors that can contribute to cardiovascular death.
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Affiliation(s)
- Ștefania-Teodora Duca
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Mihai Roca
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiovascular Rehabilitation, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Alexandru-Dan Costache
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiovascular Rehabilitation, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Adriana Chetran
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Irina Afrăsânie
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Radu-Ștefan Miftode
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Ionuț Tudorancea
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
- Department of Morpho-Functional Science II-Physiology, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
| | - Iulian Matei
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Radu-George Ciorap
- Department of Biomedical Science, Faculty of Medical Bioengineering, University of Medicine and Pharmacy "Grigore T. Popa", 700145 Iasi, Romania
| | - Ovidiu Mitu
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Minerva Codruța Bădescu
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of III Internal Medicine Clinic, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
| | - Dan Iliescu-Halitchi
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, Arcadia Hospital, 700620 Iasi, Romania
| | - Codruța-Olimpiada Halițchi-Iliescu
- Department of Mother and Child Medicine-Pediatrics, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Pedriatics, Arcadia Hospital, 700620 Iasi, Romania
| | - Florin Mitu
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiovascular Rehabilitation, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Cătălina Lionte
- Department of Internal Medicine III, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700145 Iasi, Romania
- Department of Cardiology, Helicomed Hospital, 700115 Iasi, Romania
| | - Irina-Iuliana Costache
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 700115 Iasi, Romania
- Department of Cardiology, "St. Spiridon" Emergency County Hospital, 700111 Iasi, Romania
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Hekkanen JJ, Kenttä TV, Holmström L, Tulppo MP, Ukkola OH, Pakanen L, Junttila MJ, Huikuri HV, Perkiömäki JS. Association of electrocardiographic spatial heterogeneity of repolarization and spatial heterogeneity of atrial depolarization with left ventricular fibrosis. Europace 2023; 25:820-827. [PMID: 36635858 PMCID: PMC10062366 DOI: 10.1093/europace/euac273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/14/2022] [Indexed: 01/14/2023] Open
Abstract
AIMS To evaluate the relationship between spatial heterogeneity of electrocardiographic repolarization and spatial heterogeneity of atrial depolarization with arrhythmic substrate represented by left ventricular fibrosis. METHODS AND RESULTS We assessed the associations of T- and P-wave morphology parameters analysed from the standard 12-lead electrocardiograms with left ventricular fibrosis in 378 victims of unexpected sudden cardiac death (SCD) who underwent medico-legal autopsy. Based on autopsy findings, the SCD victims were categorized into four different groups according to different stages of severity of left ventricular fibrosis (substantial fibrosis, moderate patchy fibrosis, scattered mild fibrosis, no fibrosis). T-wave and P-wave area dispersion (TWAd: 0.0841 ± 0.496, 0.170 ± 0.492, 0.302 ± 404, 0.296 ± 0.476, P = 0.008; PWAd: 0.574 ± 0.384, 0.561 ± 0.367, 0.654 ± 0.281, 0.717 ± 0.257, P = 0.011, respectively; low values abnormal), non-dipolar components of T-wave and P-wave morphology (T_NonDipolarABS: 0.0496 ± 0.0377, 0.0571 ± 0.0487, 0.0432 ± 0.0476, 0.0380 ± 0.0377, P = 0.027; P_NonDipolarABS: 0.0132 ± 0.0164, 0.0130 ± 0.0135, 0.0092 ± 0.0117, 0.0069 ± 0.00472, P = 0.005, respectively, high values abnormal), T-wave morphology dispersion (TMD: 45.9 ± 28.3, 40.5 ± 25.8, 35.5 ± 24.9, 33.0 ± 24.6, P = 0.030, respectively, high values abnormal), and P-wave heterogeneity (PWH: 20.0 ± 9.44, 19.7 ± 8.87, 17.9 ± 9.78, 15.4 ± 4.60, P = 0.019, respectively, high values abnormal) differed significantly between the groups with different stages of left ventricular fibrosis. After adjustment with heart weight, T_NonDipolarABS [standardized β (sβ) = 0.131, P = 0.014], PWAd (sβ = -0.161, P = 0.003), P_NonDipolarABS (sβ = 0.174, P = 0.001), and PWH (sβ = 0.128, P = 0.015) retained independent association, and TWAd (sβ = -0.091, P = 0.074) and TMD (sβ = 0.097, P = 0.063) tended to retain their association with the degree of myocardial fibrosis. CONCLUSION Our findings suggest that abnormal values of T- and P-wave morphology are associated with arrhythmic substrate represented by ventricular fibrosis partly explaining the mechanism behind their prognostic significance.
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Affiliation(s)
- Jenni J Hekkanen
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Lauri Holmström
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Mikko P Tulppo
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Lasse Pakanen
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Hoitajanrinne 1, P.O. Box 310, FI-90101 Oulu, Finland
- Department of Forensic Medicine, Medical Research Center Oulu, Research Unit of Internal Medicine, University of Oulu, Aapistie 5B, P.O. Box 5000, FI-90014 Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Division of Cardiology, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, P.O. Box 5000, Kajaanintie 50, 90014 Oulu, Finland
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Laitinen I, Kenttä TV, Passi J, Haukilahti MAE, Eranti A, Holkeri A, Aro AL, Kerola T, Noponen K, Seppänen T, Rissanen H, Knekt P, Heliövaara M, Ukkola OH, Junttila MJ, Huikuri HV, Perkiömäki JS. Prognostic value of P-wave morphology in general population. Europace 2023; 25:164-174. [PMID: 35852923 PMCID: PMC10112844 DOI: 10.1093/europace/euac121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 06/19/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS To evaluate the prognostic significance of novel P-wave morphology descriptors in general population. METHODS AND RESULTS Novel P-wave morphology variables were analyzed from orthogonal X-, Y-, Z-leads of the digitized electrocardiogram using a custom-made software in 6906 middle-aged subjects of the Mini-Finland Health Survey. A total of 3747 (54.3%) participants died during the follow-up period of 24.3 ± 10.4 years; 379 (5.5%) of the study population succumbed to sudden cardiac death (SCD), 928 (13.4%) to non-SCD (NSCD) and 2440 (35.3%) patients to non-cardiac death (NCD). In univariate comparisons, most of the studied P-wave morphology parameters had a significant association with all modes of death (P from <0.05 to <0.001). After relevant adjustments in the Cox multivariate hazards model, P-wave morphology dispersion (PMD) still tended to predict SCD [hazard ratio (HR): 1.006, 95% confidence interval (CI): 1.000-1.012, P = 0.05) but not NSCD (HR: 0.999, 95% CI: 0.995-1.003, P = 0.68) or NCD (HR: 0.999, 95% CI: 0.997-1.001, P = 0.44). The P-wave maximum amplitude in the lead Z (P-MaxAmp-Z) predicted SCD even after multivariate adjustments (HR: 1.010, 95% CI: 1.005-1.015, P = 0.0002) but also NSCD (HR: 1.005, 95% CI: 1.002-1.009, P = 0.0005) and NCD (HR: 1.002, 95% CI: 1.000-1.005, P = 0.03). CONCLUSION Abnormalities of P-wave morphology are associated with the risk of all modes of death in general population. After relevant adjustments, PMD was still closely associated with the risk of SCD but not with NSCD or NCD. P-MaxAmp-Z predicted SCD even after adjustments, however, it also retained its association with NSCD and NCD.
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Affiliation(s)
- Idamaria Laitinen
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Jussi Passi
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Mira Anette E Haukilahti
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Antti Eranti
- Heart Center, Turku University Hospital, Turku, Finland
| | - Arttu Holkeri
- Division of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Aapo L Aro
- Division of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tuomas Kerola
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | - Kai Noponen
- Center for Machine Vision and Signal Analysis, University of Oulu, Oulu, Finland
| | - Tapio Seppänen
- Center for Machine Vision and Signal Analysis, University of Oulu, Oulu, Finland
| | - Harri Rissanen
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Paul Knekt
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | | | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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7
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Verrier RL, Varma N, Nearing BD. Continuous multi-day tracking of post-myocardial infarction recovery of cardiac electrical stability and autonomic tone using electrocardiogram patch monitors. Ann Noninvasive Electrocardiol 2023; 28:e13035. [PMID: 36630149 PMCID: PMC9833356 DOI: 10.1111/anec.13035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/30/2022] [Accepted: 12/04/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Sudden cardiac death (SCD) risk is elevated following acute myocardial infarction (MI). The time course of SCD susceptibility post-MI requires further investigation. METHODS In this observational cohort study, we employed state-of-the-art noninvasive ECG techniques to track the daily time course of cardiac electrical instability and autonomic function following ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). Preventice BodyGuardian MINI-EL Holters continuously recorded ECGs for 7 days at hospital discharge and at 40 days for STEMI (N = 5) or at 90 days for NSTEMI patients (N = 5). Cardiac electrical instability was assessed by T-wave alternans (TWA) and T-wave heterogeneity (TWH); autonomic tone was determined by rMSSD-heart rate variability (HRV). RESULTS TWA was severely elevated (≥60 μV) in STEMI patients (80 ± 10.3 μV) at discharge and throughout the first recording period but declined by 50% to 40 ± 2.3 μV (p = .03) by Day 40 and remained in the normal range (<47 μV). TWH, a related phenomenon analyzed from 12-lead ECGs, was reduced by 63% in the five STEMI patients from discharge to normal (<80 μV) at follow-up (105 ± 27.3 to 39 ± 3.3 μV, p < .04) but increased by 65% in a STEMI case (89 to 147 μV), who received a wearable defibrillator vest and later implantable cardioverter defibrillator. In NSTEMI patients, TWA was borderline abnormal (47 ± 3.3 μV) at discharge and declined by 19% to normal (38 ± 1.2 μV) by Day 90 (p = .05). An overall reciprocal increase in rMSSD-HRV suggested recovery of vagal tone. CONCLUSIONS This study provides proof-of-principle for tracking post-MI SCD risk in individual patients with implications for personalized therapy.
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Affiliation(s)
- Richard L. Verrier
- Department of Medicine, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Bruce D. Nearing
- Department of Medicine, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusettsUSA
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8
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L Fialho G, Lin K. T-wave heterogeneity in epilepsy: Could we kill two (or three) birds with one stone? Epilepsy Behav 2022; 134:108747. [PMID: 35637101 DOI: 10.1016/j.yebeh.2022.108747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Guilherme L Fialho
- Cardiology Division, Federal University of Santa Catarina, (UFSC), Florianópolis, SC, Brazil; Medical Sciences Post-graduate Program, Federal University of Santa Catarina, (UFSC), Florianópolis, SC, Brazil.
| | - Katia Lin
- Medical Sciences Post-graduate Program, Federal University of Santa Catarina, (UFSC), Florianópolis, SC, Brazil; Center for Applied Neurosciences (CeNAp), Federal University of Santa Catarina, (UFSC), Florianópolis, SC, Brazil; Neurology Division, Federal University of Santa Catarina, (UFSC), Florianópolis, SC, Brazil.
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9
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Pang TD, Nearing BD, Verrier RL, Schachter SC. T-wave heterogeneity crescendo in the surface EKG is superior to heart rate acceleration for seizure prediction. Epilepsy Behav 2022; 130:108670. [PMID: 35367725 DOI: 10.1016/j.yebeh.2022.108670] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/12/2022] [Accepted: 03/14/2022] [Indexed: 11/19/2022]
Abstract
We examined whether T-wave heterogeneity (TWH) on the surface electrocardiographic (EKG) could predict epileptic seizure onset. Patients with electroencephalography-confirmed generalized tonic-clonic seizures (GTCS) (n = 6) exhibited abnormal elevations in TWH (>80 µV) at baseline (105 ± 20.4 µV), which increased from 30 min prior to seizure without heart rate increases > 2 beats/min until 10 min pre-seizure. Specifically, TWH on 3-lead surface EKG patch recordings increased from 1-hour baseline to 30 min (<0.05), 20 min (p < 0.002), 10 min (p = 0.01), and 1 min (p = 0.01) before seizure onset. At 10 min following GTCS, TWH returned to 110 ± 20.3 µV, similar to baseline (p = 0.54). This pre-ictal TWH warning pattern was not present in patients with psychogenic nonepileptic seizures (PNES) (n = 3), as TWH did not increase until PNES and returned to baseline within 10 min after PNES. Acute elevations in TWH may predict impending GTCS and may discriminate patients with GTCS from those with behaviorally similar PNES.
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Affiliation(s)
- Trudy D Pang
- Department of Neurology, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States; Harvard Medical School, 99 Brookline Avenue, RN-301, Boston, MA 02215, United States.
| | - Bruce D Nearing
- Harvard Medical School, 99 Brookline Avenue, RN-301, Boston, MA 02215, United States; Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States.
| | - Richard L Verrier
- Harvard Medical School, 99 Brookline Avenue, RN-301, Boston, MA 02215, United States; Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States.
| | - Steven C Schachter
- Department of Neurology, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, United States; Harvard Medical School, 99 Brookline Avenue, RN-301, Boston, MA 02215, United States; Massachusetts General Hospital, Boston, MA, United States; Consortia for Improving Medicine with Innovation & Technology (CIMIT), 125 Nashua St., Suite 324, Boston, MA 02114, United States.
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10
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Schüttler D, Tomsits P, Bleyer C, Vlcek J, Pauly V, Hesse N, Sinner M, Merkus D, Hamers J, Kääb S, Clauss S. A practical guide to setting up pig models for cardiovascular catheterization, electrophysiological assessment and heart disease research. Lab Anim (NY) 2022; 51:46-67. [PMID: 35087256 DOI: 10.1038/s41684-021-00909-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 12/15/2021] [Indexed: 01/09/2023]
Abstract
Over the past years, the use of large animals has become increasingly interesting in translational research, to bridge the gap between basic research in rodents and targeted therapies in humans. Pigs are highly valued in cardiovascular research because of their anatomical, hemodynamic and electrophysiological features, which closely resemble those of humans. For studying these aspects in swine, cardiac catheterization techniques are essential procedures. Although cardiac catheterization seems to be comparatively easy in pigs as human equipment can be used to perform the procedure, there are some pitfalls. Here we provide a detailed protocol to guide the reader through different aspects of cardiac catheterization in pigs. We suggest an approach for safe intubation and extubation, provide tips for perioperative and postoperative management of the animals and guide the reader through different experimental steps, including sheath insertion. We also describe the procedures for basic electrophysiological assessment of conduction properties and atrial fibrillation induction, hemodynamic assessment via pressure-volume loops, right heart and left heart catheterization and the development of a myocardial infarction model by balloon occlusion. This protocol was developed in Landrace pigs and can be adapted to other pig breeds or other large animal species. This protocol requires approximately six and a half working hours in total and should be performed by researchers with previous experience in large animal experimentation and in the presence of a veterinarian.
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Affiliation(s)
- Dominik Schüttler
- Medizinische Klinik und Poliklinik I, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany
| | - Philipp Tomsits
- Medizinische Klinik und Poliklinik I, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany
| | - Christina Bleyer
- Medizinische Klinik und Poliklinik I, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany
| | - Julia Vlcek
- Medizinische Klinik und Poliklinik I, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany
| | - Valerie Pauly
- Medizinische Klinik und Poliklinik I, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany
| | - Nora Hesse
- Medizinische Klinik und Poliklinik I, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany
| | - Moritz Sinner
- Medizinische Klinik und Poliklinik I, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany
| | - Daphne Merkus
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany.,Division of Experimental Cardiology, Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jules Hamers
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany.,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany
| | - Stefan Kääb
- Medizinische Klinik und Poliklinik I, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany
| | - Sebastian Clauss
- Medizinische Klinik und Poliklinik I, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany. .,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany. .,Institute of Surgical Research at the Walter-Brendel-Centre of Experimental Medicine, LMU Hospital, Ludwig-Maximilians-Universität Munich (LMU), Munich, Germany.
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11
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Jaber S, Nussinovitch U, Stahi T, Arnson Y. Association between T wave morphology parameters and abnormal cardiac SPECT imaging. J Electrocardiol 2021; 70:65-69. [PMID: 34929606 DOI: 10.1016/j.jelectrocard.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND T-wave morphology dispersion (TMD) described the electrocardiographic T-wave heterogeneity during a single cardiac cycle. Total cosine R-to-T (TCRT) is the average of the cosines of the angles between the QRS and T vectors on the ECG. We examine the predictive value of TMD and TCRT calculation to assess abnormal myocardial perfusion. METHODS Retrospective single center cohort study including all patients referred for evaluation of ischemia by myocardial SPECT scanning with no known history of ischemic heart disease, from 1 January 2019 to 31 December 2019. Study endpoint was the correlation between the calculated TMD and TCRT values and detection of myocardial injury or ischemia by myocardial SPECT. RESULTS Among 606 patients, calculated TCRT was 0.401 ± 0.53 for the normal group and 0.283 ± 0.62 for the abnormal group (p = 0.007). Measured TMD was 22.9 ± 16.6 degrees (p < 0.001) in the normal group, compared to 31.5 ± 22.8 degrees (p < 0.001) for the abnormal group. CONCLUSIONS The results demonstrate a correlation between the decreased TCRT values and increase TMD and myocardial ischemia seen in SPECT results. The TCRT and TMD can be used as simple and non-invasive markers to predict abnormal SPECT results and ischemic heart disease in patients with no known cardiac history.
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Affiliation(s)
- Samer Jaber
- Internal Medicine "F", Meir Medical Center, Kfar Sava, Israel
| | - Udi Nussinovitch
- Department of Cardiology, Meir Medical Center, Kfar Sava, Israel; Applicative Cardiovascular Research Center (ACRC), Meir Medical Center, Kfar Sava, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Tomer Stahi
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Yoav Arnson
- Department of Cardiology, Meir Medical Center, Kfar Sava, Israel; Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
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12
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Araujo Silva B, Hauser TH, Nearing BD, Bortolotto AL, Marum AA, Tessarolo Silva F, Medeiros SA, Pedreira GC, Gervino EV, Verrier RL. Regadenoson-induced T-wave heterogeneity complements coronary stenosis detection by myocardial perfusion imaging in men and women. Eur Heart J Cardiovasc Imaging 2021; 22:1341-1349. [PMID: 32620962 DOI: 10.1093/ehjci/jeaa128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 03/30/2020] [Accepted: 04/25/2020] [Indexed: 12/31/2022] Open
Abstract
AIMS We analysed whether incorporating electrocardiographic interlead T-wave heterogeneity (TWH) with myocardial perfusion imaging (MPI) during pharmacologic stress improves detection of flow-limiting lesions (FLL). METHODS AND RESULTS Medical records of all 103 patients at our institution who underwent stress testing with regadenoson (0.4 mg IV bolus) within 3 months of coronary angiography from September 2017 to March 2019 were studied. Cases (N = 59) had angiographically significant FLL (≥50% of left main or ≥70% of other epicardial coronary arteries ≥2 mm in diameter); controls (N = 44) were normal or had non-FLL. TWH, i.e., interlead splay of T waves, was assessed from precordial leads V4-6 by second central moment analysis. Maximum TWHV4-6 levels during regadenoson stress were 68% higher in cases than in controls (P < 0.0001). TWHV4-6 generated areas under the receiver-operating characteristic (ROC) curve of 0.79 in men (P < 0.0001) and 0.71 in women (P = 0.007). In men, the ROC-guided 54-µV TWHV4-6 cut-point for FLL produced adjusted odds of 7.3 [95% confidence interval (CI): 1.3-41.5, P = 0.03], 79% sensitivity, and 78% specificity. In women, the ROC-guided 35-µV TWHV4-6 cut-point produced adjusted odds of 4.5 (95% CI: 1.1-18.9, P = 0.04), 84% sensitivity, and 52% specificity. Adding TWHV4-6 to MPI determinations reduced false-positive results by 70%, more than doubled true-negative results, and improved adjusted odds ratio to 6.8 (95% CI: 2.2-21.4, P = 0.001) with specificity of 78% in men and 86% in women. CONCLUSION This observational study is the first to demonstrate the benefit of combining TWHV4-6 with MPI to enhance FLL detection during MPI with regadenoson in both men and women.
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Affiliation(s)
- Bruna Araujo Silva
- Cardiovascular Medicine Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.,Faculdade de Medicina da Universidade de São Paulo, Avenida Doutor Arnaldo, 255, São Paulo, SP, 05430-000, Brazil
| | - Thomas H Hauser
- Cardiovascular Medicine Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Bruce D Nearing
- Cardiovascular Medicine Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Alexandre L Bortolotto
- Cardiovascular Medicine Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.,Faculdade de Medicina da Universidade de São Paulo, Avenida Doutor Arnaldo, 255, São Paulo, SP, 05430-000, Brazil
| | - Alexandre A Marum
- Cardiovascular Medicine Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.,Faculdade de Medicina da Universidade de São Paulo, Avenida Doutor Arnaldo, 255, São Paulo, SP, 05430-000, Brazil
| | - Fernanda Tessarolo Silva
- Cardiovascular Medicine Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.,Faculdade de Medicina da Universidade de São Paulo, Avenida Doutor Arnaldo, 255, São Paulo, SP, 05430-000, Brazil
| | - Sofia A Medeiros
- Cardiovascular Medicine Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.,Faculdade de Medicina da Universidade de São Paulo, Avenida Doutor Arnaldo, 255, São Paulo, SP, 05430-000, Brazil
| | - Giovanna C Pedreira
- Cardiovascular Medicine Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.,Faculdade de Medicina da Universidade de São Paulo, Avenida Doutor Arnaldo, 255, São Paulo, SP, 05430-000, Brazil
| | - Ernest V Gervino
- Cardiovascular Medicine Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Richard L Verrier
- Cardiovascular Medicine Division, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
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13
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Verrier RL, Nearing BD, D'Avila A. Spectrum of clinical applications of interlead ECG heterogeneity assessment: From myocardial ischemia detection to sudden cardiac death risk stratification. Ann Noninvasive Electrocardiol 2021; 26:e12894. [PMID: 34592018 PMCID: PMC8588374 DOI: 10.1111/anec.12894] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/23/2021] [Accepted: 09/03/2021] [Indexed: 12/11/2022] Open
Abstract
Heterogeneity in depolarization and repolarization among regions of cardiac cells has long been recognized as a major factor in cardiac arrhythmogenesis. This fundamental principle has motivated development of noninvasive techniques for quantification of heterogeneity using the surface electrocardiogram (ECG). The initial approaches focused on interval analysis such as interlead QT dispersion and Tpeak -Tend difference. However, because of inherent difficulties in measuring the termination point of the T wave and commonly encountered irregularities in the apex of the T wave, additional techniques have been pursued. The newer methods incorporate assessment of the entire morphology of the T wave and in some cases of the R wave as well. This goal has been accomplished using a number of promising vectorial approaches with the resting 12-lead ECG. An important limitation of vectorcardiographic analyses is that they require exquisite stability of the recordings and are not inherently suitable for use in exercise tolerance testing (ETT) and/or ambulatory ECG monitoring for provocative stress testing or evaluation of the influence of daily activities on cardiac electrical instability. The objectives of the present review are to describe a technique that has been under clinical evaluation for nearly a decade, termed "interlead ECG heterogeneity." Preclinical testing data will be briefly reviewed. We will discuss the main clinical findings with regard to sudden cardiac death risk stratification, heart failure evaluation, and myocardial ischemia detection using standard recording platforms including resting 12-lead ECG, ambulatory ECG monitoring, ETT, and pharmacologic stress testing in conjunction with single-photon emission computed tomography myocardial perfusion imaging.
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Affiliation(s)
- Richard L Verrier
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce D Nearing
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andre D'Avila
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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14
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Verrier RL, Pang TD, Nearing BD, Schachter SC. Epileptic heart: A clinical syndromic approach. Epilepsia 2021; 62:1780-1789. [PMID: 34236079 DOI: 10.1111/epi.16966] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 12/15/2022]
Abstract
Prevention of premature death in patients with chronic epilepsy remains a major challenge. Multiple pathophysiologic factors have been implicated, with intense investigation of cardiorespiratory mechanisms. Up to four in five patients with chronic epilepsy exhibit cardiovascular comorbidities. These findings led us to propose the concept of an "epileptic heart," defined as "a heart and coronary vasculature damaged by chronic epilepsy as a result of repeated surges in catecholamines and hypoxemia leading to electrical and mechanical dysfunction." Among the most prominent changes documented in the literature are high incidence of myocardial infarction and arrhythmia, altered autonomic tone, diastolic dysfunction, hyperlipidemia, and accelerated atherosclerosis. This suite of pathologic changes prompted us to propose for the first time in this review a syndromic approach for improved clinical detection of the epileptic heart condition. In this review, we discuss the key pathophysiologic mechanisms underlying the candidate criteria along with standard and novel techniques that permit evaluation of each of these factors. Specifically, we present evidence of the utility of standard 12-lead, ambulatory, and multiday patch-based electrocardiograms, along with measures of cardiac electrical instability, including T-wave alternans, heart rate variability to detect altered autonomic tone, echocardiography to detect diastolic dysfunction, and plasma biomarkers for assessing hyperlipidemia and accelerated atherosclerosis. Ultimately, the proposed clinical syndromic approach is intended to improve monitoring and evaluation of cardiac risk in patients with chronic epilepsy to foster improved therapeutic strategies to reduce premature cardiac death.
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Affiliation(s)
- Richard L Verrier
- Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Trudy D Pang
- Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Bruce D Nearing
- Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Steven C Schachter
- Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Consortia for Improving Medicine with Innovation and Technology, Boston, Massachusetts, USA
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15
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Monteiro FR, Rabelo Evangelista AB, Nearing BD, Medeiros SA, Tessarolo Silva F, Pedreira GC, Ullman E, Gervino EV, Verrier RL. T-wave heterogeneity in standard resting 12-lead ECGs is associated with 90-day cardiac mortality in women following emergency department admission: A nested case-control study. Ann Noninvasive Electrocardiol 2021; 26:e12826. [PMID: 33543816 PMCID: PMC8164148 DOI: 10.1111/anec.12826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 01/06/2023] Open
Abstract
Background We investigated whether T‐wave heterogeneity (TWH) can identify patients who are at risk for near‐term cardiac mortality. Methods A nested case–control analysis was performed in the 888 patients admitted to the Emergency Department (ED) of our medical center in July through September 2018 who had ≥2 serial troponin measurement tests within 6 hr for acute coronary syndrome evaluation to rule‐in or rule‐out the presence of acute myocardial infarction. Patients who died from cardiac causes during 90 days after ED admission were considered cases (n = 20; 10 women) and were matched 1:4 on sex and age with patients who survived during this period (n = 80, 40 women). TWH, that is, interlead splay of T waves, was automatically assessed from precordial leads by second central moment analysis. Results TWHV4‐6 was significantly elevated at ED admission in 12‐lead resting ECGs of female patients who died of cardiac causes during the following 90 days compared to female survivors (100 ± 14.9 vs. 40 ± 3.6 µV, p < .0001). TWHV4‐6 generated areas under the receiver‐operating characteristic (ROC) curve (AUC) of 0.933 in women (p < .0001) and 0.573 in men (p = .4). In women, the ROC‐guided 48‐µV TWHV4‐6 cut point for near‐term cardiac mortality produced an adjusted odds ratio of 121.37 (95% CI: 2.89–6,699.84; p = .02) with 100% sensitivity and 82.5% specificity. In Kaplan–Meier survival analysis, TWHV4‐6 ≥ 48 µV predicted cardiac mortality in women during 90‐day follow‐up with a hazard ratio of 27.84 (95% CI: 7.29–106.36, p < .0001). Conclusion Elevated TWHV4‐6 is associated with near‐term cardiac mortality among women evaluated for acute coronary syndrome.
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Affiliation(s)
- Felipe R Monteiro
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Ana B Rabelo Evangelista
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bruce D Nearing
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sofia A Medeiros
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fernanda Tessarolo Silva
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Giovanna C Pedreira
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Edward Ullman
- Harvard Medical School, Boston, MA, USA.,Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ernest V Gervino
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Richard L Verrier
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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16
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Chauhan VS, Martínez JP, van der Heyden MAG. Commentary: Increased Beat-to-Beat Variability of T-Wave Heterogeneity Measured From Standard 12-Lead Electrocardiogram Is Associated With Sudden Cardiac Death: A Case-Control Study. Front Physiol 2020; 11:598314. [PMID: 33192614 PMCID: PMC7604440 DOI: 10.3389/fphys.2020.598314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/08/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
- Vijay S Chauhan
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Juan Pablo Martínez
- Aragón Institute of Engineering Research, IIS Aragón, Universidad de Zaragoza, Zaragoza, Spain.,Biomedical Research Networking Center in Bioengineering, Biomaterials, and Nanomedicine (CIBER-BBN), Zaragoza, Spain
| | - Marcel A G van der Heyden
- Division of Heart & Lungs, Department of Medical Physiology, University Medical Center Utrecht, Utrecht, Netherlands
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17
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Nearing BD, Anand IS, Libbus I, Dicarlo LA, Kenknight BH, Verrier RL. Vagus Nerve Stimulation Provides Multiyear Improvements in Autonomic Function and Cardiac Electrical Stability in the ANTHEM-HF Study. J Card Fail 2020; 27:208-216. [PMID: 33049374 DOI: 10.1016/j.cardfail.2020.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with heart failure with reduced left ventricular ejection fraction (LVEF) (HFrEF) experience long-term deterioration of autonomic function and cardiac electrical stability linked to increased mortality risk. The Autonomic Neural Regulation Therapy to Enhance Myocardial Function in Heart Failure (ANTHEM-HF) trial reported improved heart rate variability (HRV) and heart rate turbulence (HRT) and reduced T-wave alternans (TWA) after 12 months of vagus nerve stimulation (VNS). We investigated whether the benefits of chronic VNS persist in the long term. METHODS AND RESULTS Effects of chronic VNS on heart rate, HRV, HRT, TWA, R-wave and T-wave heterogeneity (RWH, TWH), and nonsustained ventricular tachycardia (NSVT) incidence were evaluated in all ANTHEM-HF patients with ambulatory ECG data at 24 and 36 months (n = 25). Autonomic markers improved significantly at 24 and 36 months compared to baseline [heart rate, square root of the mean squared differences of successive normal-to-normal intervals (rMSSD), standard deviation of the normal-to-normal intervals (SDNN), HF-HRV, HRT slope, P < 0.05]. Peak TWA levels remained reduced at 24 and 36 months (P < 0.0001). Reductions in RWH and TWH at 6 and 12 months persisted at 24 and 36 months (P < 0.01). NSVT decreased at 12, 24, and 36 months (P < 0.025). No sudden cardiac deaths, ventricular fibrillation, or sustained ventricular tachycardia occurred. CONCLUSION In symptomatic patients with HFrEF, chronic VNS appears to confer wide-ranging, persistent improvements in autonomic tone (HRV), baroreceptor sensitivity (HRT), and cardiac electrical stability (TWA, RWH, TWH).
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Affiliation(s)
- Bruce D Nearing
- Beth Israel Deaconess Medical Center, Division of Cardiovascular Medicine, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | - Richard L Verrier
- Beth Israel Deaconess Medical Center, Division of Cardiovascular Medicine, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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18
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Hekkanen JJ, Kenttä TV, Haukilahti MAE, Rahola JT, Holmström L, Vähätalo J, Tulppo MP, Kiviniemi AM, Pakanen L, Ukkola OH, Junttila MJ, Huikuri HV, Perkiömäki JS. Increased Beat-to-Beat Variability of T-Wave Heterogeneity Measured From Standard 12-Lead Electrocardiogram Is Associated With Sudden Cardiac Death: A Case-Control Study. Front Physiol 2020; 11:1045. [PMID: 32982784 PMCID: PMC7477294 DOI: 10.3389/fphys.2020.01045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/29/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction The prognostic significance of beat-to-beat variability of spatial heterogeneity of repolarization measured from standard 12-lead ECG is not well-understood. Methods We measured the short-term variability of repolarization parameters, such as T-wave heterogeneity in leads V4–V6 (TWH) and QT interval (QT), from five consecutive beats of previously recorded standard 12-lead ECG in 200 victims of unexpected sudden cardiac death (SCD) confirmed to be due to complicated atherosclerotic coronary artery disease (CAD) in medico-legal autopsy and 200 age- and sex-matched controls with angiographically confirmed CAD. The short-term variability of repolarization heterogeneity was defined as the standard deviation (SD) of the measured repolarization parameters. All ECGs were in sinus rhythm, and no premature ventricular contractions were included in the measured segment. Results TWH-SD and QT-SD were significantly higher in SCD victims than in subjects with CAD (6.9 ± 5.6 μV vs. 3.8 ± 2.6 μV, p = 1.8E-11; 8.3 ± 13.1 ms vs. 3.8 ± 7.1 ms, p = 0.00003, respectively). After adjusting in the multivariate clinical model with factors, such as diabetes, RR interval, and beta blocker medication, TWH-SD and QT-SD retained their significant power in discriminating between the victims of SCD and the patients with CAD (p = 0.00003, p = 0.006, respectively). TWH-SD outperformed QT-SD in identifying the SCD victims among the study subjects (area under the curve in the receiver operating characteristics curve 0.730 vs. 0.679, respectively). Conclusion Increased short-term variability of repolarization heterogeneity measured from standard 12-lead ECG is associated with SCD.
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Affiliation(s)
- Jenni J Hekkanen
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Tuomas V Kenttä
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Mira Anette E Haukilahti
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Janne T Rahola
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Lauri Holmström
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Juha Vähätalo
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Mikko P Tulppo
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Antti M Kiviniemi
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Lasse Pakanen
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Oulu, Finland.,Research Unit of Internal Medicine, Department of Forensic Medicine, Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Olavi H Ukkola
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - M Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Heikki V Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Juha S Perkiömäki
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
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19
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Bortolotto AL, Verrier RL, Nearing BD, Marum AA, Araujo Silva B, Pedreira GC, Tessarolo Silva F, Medeiros SA, Sroubek J, Zimetbaum PJ, Chang JD. Preimplantation interlead ECG heterogeneity is superior to QRS complex duration in predicting mechanical super-response in patients with non-left bundle branch block receiving cardiac resynchronization therapy. Heart Rhythm 2020; 17:1887-1896. [PMID: 32497764 DOI: 10.1016/j.hrthm.2020.05.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/27/2020] [Accepted: 05/27/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Reliable quantitative preimplantation predictors of response to cardiac resynchronization therapy (CRT) are needed. OBJECTIVE We tested the utility of preimplantation R-wave and T-wave heterogeneity (RWH and TWH, respectively) compared to standard QRS complex duration in identifying mechanical super-responders to CRT and mortality risk. METHODS We analyzed resting 12-lead electrocardiographic recordings from all 155 patients who received CRT devices between 2006 and 2018 at our institution and met class I and IIA American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines with echocardiograms before and after implantation. Super-responders (n=35, 23%) had ≥20% increase in left ventricular ejection fraction and/or ≥20% decrease in left ventricular end-systolic diameter and were compared with non-super-responders (n=120, 77%), who did not meet these criteria. RWH and TWH were measured using second central moment analysis. RESULTS Among patients with non-left bundle branch block (LBBB), preimplantation RWH was significantly lower in super-responders than in non-super-responders in 3 of 4 lead sets (P=.001 to P=.038) and TWH in 2 lead sets (both, P=.05), with the corresponding areas under the curve (RWH: 0.810-0.891, P<.001; TWH: 0.759-0.810, P≤.005). No differences were observed in the LBBB group. Preimplantation QRS complex duration also did not differ between super-responders and non-super-responders among patients with (P=.856) or without (P=.724) LBBB; the areas under the curve were nonsignificant (both, P=.69). RWHV1-3LILII ≥ 420 μV predicted 3-year all-cause mortality in the entire cohort (P=.037), with a hazard ratio of 7.440 (95% confidence interval 1.015-54.527; P=.048); QRS complex duration ≥ 150 ms did not predict mortality (P=.27). CONCLUSION Preimplantation interlead electrocardiographic heterogeneity but not QRS complex duration predicts mechanical super-response to CRT in patients with non-LBBB.
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Affiliation(s)
- Alexandre L Bortolotto
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Richard L Verrier
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Bruce D Nearing
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Alexandre A Marum
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bruna Araujo Silva
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Giovanna C Pedreira
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fernanda Tessarolo Silva
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Sofia A Medeiros
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Jakub Sroubek
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Peter J Zimetbaum
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - James D Chang
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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20
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Lombardi F, Vicenzi M, Hnatkova K, Schmidt G, Malik M. The search for non-invasive markers of cardiac diseases comes back to the 12-lead electrocardiogram. Int J Cardiol 2020; 298:55-56. [DOI: 10.1016/j.ijcard.2019.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/07/2019] [Indexed: 11/26/2022]
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21
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Silva AC, de Antonio VZ, Sroubek J, Gervino E, Ho K, Medeiros SA, Silva FT, Pedreira GC, Stocco FG, Nearing BD, Verrier RL. Exercise and pharmacologic stress-induced interlead T-wave heterogeneity analysis to detect clinically significant coronary artery stenosis. Int J Cardiol 2020; 298:32-38. [PMID: 31412992 DOI: 10.1016/j.ijcard.2019.07.066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 07/08/2019] [Accepted: 07/22/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite widespread use of ETT and vasodilator-stress with myocardial perfusion imaging (MPI) for noninvasive detection of flow-limiting coronary artery disease, there is continued need to improve diagnostic accuracy. We examined whether measurement of interlead T-wave heterogeneity (TWH) during exercise tolerance testing (ETT) or pharmacologic stress testing improves detection of stenoses in large epicardial coronary arteries. METHODS All 137 patients at our institution who underwent diagnostic coronary angiography within 0 to 5 days after ETT (N = 81) or dipyridamole IV infusion (N = 58) in 2016 were studied, including 2 patients with both tests. Cases (N = 93) had angiographically significant stenosis (≥50% of left main or ≥ 70% of an epicardial coronary artery ≥2 mm in diameter); controls (N = 44) did not. TWH, i.e., interlead splay of T waves, was determined by second central moment analysis from precordial leads by an investigator blinded to angiographic results. RESULTS At rest, TWH levels were similar for cases and controls. ETT and dipyridamole stress testing increased TWH by 69% (p < 0.0001) and 27% (p < 0.0001), respectively, in cases. In controls, TWH did not change. Areas under the ROC curves for TWH increase for any flow-limiting coronary artery stenosis were 0.737 (p < 0.0001) for ETT and 0.818 (p < 0.0001) for dipyridamole stress testing. By contrast, neither ST-segment changes during ETT (p = 0.12) nor MPI during dipyridamole stress testing (p = 0.60) discriminated cases from controls. CONCLUSIONS TWH measurement is a novel method that improves detection of angiographically confirmed flow-limiting stenoses in large epicardial coronary arteries during both ETT and MPI during pharmacologic stress testing with dipyridamole.
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Affiliation(s)
- Anderson C Silva
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, United States of America; Harvard School of Public Health, Department of Environmental Sciences, Boston, MA, United States of America; Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Victor Z de Antonio
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, United States of America; Harvard School of Public Health, Department of Environmental Sciences, Boston, MA, United States of America; Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jakub Sroubek
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, United States of America; Harvard Medical School, Department of Medicine, Boston, MA, United States of America
| | - Ernest Gervino
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, United States of America; Harvard Medical School, Department of Medicine, Boston, MA, United States of America
| | - Kalon Ho
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, United States of America; Harvard Medical School, Department of Medicine, Boston, MA, United States of America
| | - Sofia A Medeiros
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, United States of America; Harvard School of Public Health, Department of Environmental Sciences, Boston, MA, United States of America; Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fernanda Tessarolo Silva
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, United States of America; Harvard School of Public Health, Department of Environmental Sciences, Boston, MA, United States of America; Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Giovanna C Pedreira
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, United States of America; Harvard School of Public Health, Department of Environmental Sciences, Boston, MA, United States of America; Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fernando G Stocco
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, United States of America; Harvard School of Public Health, Department of Environmental Sciences, Boston, MA, United States of America; Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Bruce D Nearing
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, United States of America; Harvard Medical School, Department of Medicine, Boston, MA, United States of America
| | - Richard L Verrier
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Boston, MA, United States of America; Harvard School of Public Health, Department of Environmental Sciences, Boston, MA, United States of America; Harvard Medical School, Department of Medicine, Boston, MA, United States of America.
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22
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Bonomini MP, Ortega DF, Barja LD, Mangani N, Arini PD. Depolarization spatial variance as a cardiac dyssynchrony descriptor. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2018.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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23
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Stocco FG, Evaristo E, Shah NR, Cheezum MK, Hainer J, Foster C, Nearing BD, Gervino E, Verrier RL. Marked exercise-induced T-wave heterogeneity in symptomatic diabetic patients with nonflow-limiting coronary artery stenosis. Ann Noninvasive Electrocardiol 2018; 23:e12503. [PMID: 28949056 PMCID: PMC6495190 DOI: 10.1111/anec.12503] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 08/26/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND T-wave heterogeneity (TWH) independently predicted cardiovascular mortality in Health Survey 2000 based on 12-lead ECGs recorded at rest. We investigated whether TWH is elevated during exercise tolerance testing (ETT) in symptomatic diabetic patients with nonflow-limiting coronary artery stenosis compared to control subjects without diabetes. METHODS Cases were all patients (n = 20) with analyzable ECG recordings during both rest and ETT who were enrolled in the Effects of Ranolazine on Coronary Flow Reserve (CFR) in Symptomatic Patients with Diabetes and Suspected or Known Coronary Artery Disease (RAND-CFR) study (NCT01754259); median CFR was 1.44; 80% of cases had CFR <2. Control subjects (n = 9) were nondiabetic patients who had functional flow reserve (FFR) >0.8, a range not associated with inducible ischemia. TWH was analyzed from precordial leads V4 , V5 , and V6 by second central moment analysis, which assesses the interlead splay of T-waves about a mean waveform. RESULTS During exercise to similar rate-pressure products (p = .31), RAND-CFR patients exhibited a 49% increase in TWH during exercise (rest: 49 ± 5 μV; exercise: 73 ± 8 μV, p = .003). By comparison, in control subjects, TWH was not significantly altered (rest: 52 ± 11 μV; ETT: 38 ± 5 μV, p = .19). ETT-induced ST-segment depression >1 mm (p = .11) and Tpeak -Tend (p = .18) and QTc intervals (p = .80) failed to differentiate cases from controls. CONCLUSIONS TWH is capable of detecting latent repolarization abnormalities, which are present during ETT in diabetic patients with nonflow-limiting stenosis but not in control subjects. The technique developed in this study permits TWH analysis from archived ECGs and thereby enables mining of extensive databases for retrospective studies and hypothesis testing.
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Affiliation(s)
- Fernando G. Stocco
- University of Sao Paulo School of MedicineSao PauloBrazil
- Beth Israel Deaconess Medical CenterBostonMAUSA
| | - Ederson Evaristo
- University of Sao Paulo School of MedicineSao PauloBrazil
- Beth Israel Deaconess Medical CenterBostonMAUSA
| | - Nishant R. Shah
- Brigham & Women's HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
- Brown University Warren Alpert Medical SchoolProvidenceRIUSA
| | | | | | | | - Bruce D. Nearing
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Ernest Gervino
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Richard L. Verrier
- Beth Israel Deaconess Medical CenterBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
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24
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Bui AH, Waks JW. Risk Stratification of Sudden Cardiac Death After Acute Myocardial Infarction. J Innov Card Rhythm Manag 2018; 9:3035-3049. [PMID: 32477797 PMCID: PMC7252689 DOI: 10.19102/icrm.2018.090201] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/02/2017] [Indexed: 01/20/2023] Open
Abstract
Despite advances in the diagnosis and treatment of acute coronary syndromes and an overall improvement in outcomes, mortality after myocardial infarction (MI) remains high. Sudden death, which is most frequently due to ventricular tachycardia or ventricular fibrillation, is the cause of death in 25% to 50% of patients with prior MI, and therefore represents an important public health problem. Use of the implantable cardioverter-defibrillator (ICD), which is the primary method of reducing the chance of arrhythmic sudden death after MI, is costly to the medical system and is associated with procedural and long-term risks. Additionally, assessment of left ventricular ejection fraction (LVEF), which is the primary method of assessing a patient's post-MI sudden death risk and appropriateness for ICD implantation, lacks both sensitivity and specificity for sudden death, and may not be the optimal way to select the subgroup of post-MI patients who are most likely to benefit from ICD implantation. To optimally utilize ICDs, it is therefore critical to develop and prospectively validate sudden death risk stratification methods beyond measuring LVEF. A variety of tests that assess left ventricular systolic function/morphology, potential triggers for ventricular arrhythmias, ventricular conduction/repolarization, and autonomic tone have been proposed as sudden death risk stratification tools. Multivariable models have also been developed to assess the competing risks of arrhythmic and non-arrhythmic death so that ICDs can be utilized more effectively. This manuscript will review the epidemiology of sudden death after MI, and will discuss the current state of sudden death risk stratification in this population.
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Affiliation(s)
- An H. Bui
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan W. Waks
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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25
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Kenttä TV, Sinner MF, Nearing BD, Freudling R, Porthan K, Tikkanen JT, Müller-Nurasyid M, Schramm K, Viitasalo M, Jula A, Nieminen MS, Peters A, Salomaa V, Oikarinen L, Verrier RL, Kääb S, Junttila MJ, Huikuri HV. Repolarization Heterogeneity Measured With T-Wave Area Dispersion in Standard 12-Lead ECG Predicts Sudden Cardiac Death in General Population. Circ Arrhythm Electrophysiol 2018; 11:e005762. [DOI: 10.1161/circep.117.005762] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 12/18/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Tuomas V. Kenttä
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Moritz F. Sinner
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Bruce D. Nearing
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Rebecca Freudling
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Kimmo Porthan
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Jani T. Tikkanen
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Martina Müller-Nurasyid
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Katharina Schramm
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Matti Viitasalo
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Antti Jula
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Markku S. Nieminen
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Annette Peters
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Veikko Salomaa
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Lasse Oikarinen
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Richard L. Verrier
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Stefan Kääb
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - M. Juhani Junttila
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
| | - Heikki V. Huikuri
- From the Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Finland (T.V.K., J.T.T., M.J.J., H.V.H.); Department of Medicine I, University Hospital Munich, Ludwig-Maximilians University, Germany (M.F.S., R.F., K.S., S.K.); German Cardiovascular Research Centre, Partner Site: Munich Heart Alliance (M.F.S., M.M.-N., A.P., S.K.); Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (B.D.N., R.L.V.); Institute of Genetic
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Tan AY, Nearing BD, Rosenberg M, Nezafat R, Josephson ME, Verrier RL. Interlead heterogeneity of R- and T-wave morphology in standard 12-lead ECGs predicts sustained ventricular tachycardia/fibrillation and arrhythmic death in patients with cardiomyopathy. J Cardiovasc Electrophysiol 2017; 28:1324-1333. [DOI: 10.1111/jce.13288] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/15/2017] [Accepted: 06/27/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Alex Y. Tan
- Electrophysiology Section, Division of Cardiology; Hunter Holmes McGuire VA Medical Center; Pauley Heart Center; Virginia Commonwealth University School of Medicine; Richmond VA USA
- Division of Cardiovascular Medicine; Department of Medicine, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - Bruce D. Nearing
- Division of Cardiovascular Medicine; Department of Medicine, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - Michael Rosenberg
- Division of Cardiovascular Medicine; Department of Medicine, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
- Division of Cardiology, Department of Medicine; University of Colorado School of Medicine; Denver CO USA
| | - Reza Nezafat
- Division of Cardiovascular Medicine; Department of Medicine, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - Mark E. Josephson
- Division of Cardiovascular Medicine; Department of Medicine, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - Richard L. Verrier
- Division of Cardiovascular Medicine; Department of Medicine, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
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Coll-Font J, Erem B, Brooks DH. A Potential-Based Inverse Spectral Method to Noninvasively Localize Discordant Distributions of Alternans on the Heart From the ECG. IEEE Trans Biomed Eng 2017; 65:1554-1563. [PMID: 28749343 DOI: 10.1109/tbme.2017.2732159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
T-wave alternans (TWA), defined as the beat-to-beat alternation in amplitude of the T-waves, has been shown to be linked to ventricular fibrillation (VF). However, current TWA tests have high sensitivity but low specificity in determining who is at risk. To overcome this limitation, it might be helpful to determine the spatial distribution of any regions on the heart that alternate in opposite phase. Understanding these spatial distributions in relation to the regular activation of the heart could help explain the mechanism for the genesis of VF and thus disambiguate the low specificity of TWA. GOAL Image the spatial distribution of TWA on the heart surface from ECG measurements. METHODS We introduced the inverse spectral method (ISM), a tailored inverse (or ElectroCardioGraphic Imaging) solution designed specifically to noninvasively image cases of TWA on the heart. RESULTS We evaluate the ISM on its capacity to reliably detect the spatial distributions of TWA compared against a standard TWA detection method applied directly to the electrograms on the heart surface. We report on results from both a series of synthetic simulations of TWA generated using the ECGSIM software and a set of continuous epicardial surface voltage recordings from a canine experiment. ISM detected TWA distributions that matched the phase of the true underlying out-of-phase regions over and of the heart surface, respectively. CONCLUSION Our results suggest that ISM is capable of reliably detecting the different regions present in a TWA distribution across a wide variety of TWA locations on the heart in simulation and in the face of transients and nonidealities in the canine recordings.
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Evaristo E, Stocco FG, Shah NR, Cheezum MK, Hainer J, Foster C, Nearing BD, Di Carli M, Verrier RL. Ranolazine reduces repolarization heterogeneity in symptomatic patients with diabetes and non-flow-limiting coronary artery stenosis. Ann Noninvasive Electrocardiol 2017; 23. [PMID: 28653394 DOI: 10.1111/anec.12480] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 05/11/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Experimental evidence suggests that ranolazine decreases susceptibility to ischemia-induced arrhythmias independent of effects on coronary artery blood flow. OBJECTIVE In symptomatic diabetic patients with non-flow-limiting coronary artery stenosis with diffuse atherosclerosis and/or microvascular dysfunction, we explored whether ranolazine reduces T-wave heterogeneity (TWH), an electrocardiographic (ECG) marker of arrhythmogenic repolarization abnormalities shown to predict sudden cardiac death. METHODS We studied all 16 patients with analyzable ECG recordings during rest and exercise tolerance testing before and after 4 weeks of ranolazine in the double-blind, crossover, placebo-controlled RAND-CFR trial (NCT01754259). TWH was quantified without knowledge of treatment assignment by second central moment analysis, which assesses the interlead splay of T waves in precordial leads about a mean waveform. Myocardial blood flow (MBF) was measured by positron emission tomography. RESULTS At baseline, prior to randomization, TWH during rest was 54 ± 7 μV and was not altered following placebo (47 ± 6 μV, p = .47) but was reduced by 28% (to 39 ± 5 μV, p = .002) after ranolazine. Ranolazine did not increase MBF at rest. Exercise increased TWH after placebo by 49% (to 70 ± 8 μV, p = .03). Ranolazine did not reduce TWH during exercise (to 75 ± 16 μV), and there were no differences among the groups (p = .95, ANOVA). TWH was not correlated with MBF at rest before (r2 = .07, p = .36) or after ranolazine (r2 = .23, p = .06). CONCLUSIONS In symptomatic diabetic patients with non-flow-limiting coronary artery stenosis with diffuse atherosclerosis and/or microvascular dysfunction, ranolazine reduced TWH at rest but not during exercise. Reduction in repolarization abnormalities appears to be independent of alterations in MBF.
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Affiliation(s)
- Ederson Evaristo
- Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil.,Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Fernando G Stocco
- Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil.,Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nishant R Shah
- Brigham & Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Michael K Cheezum
- Brigham & Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Brigham & Women's Hospital, Boston, MA, USA
| | | | - Bruce D Nearing
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Marcelo Di Carli
- Brigham & Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Richard L Verrier
- Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Verrier RL, Huikuri H. Tracking interlead heterogeneity of R- and T-wave morphology to disclose latent risk for sudden cardiac death. Heart Rhythm 2017; 14:1466-1475. [PMID: 28610987 DOI: 10.1016/j.hrthm.2017.06.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Indexed: 01/10/2023]
Abstract
Sudden cardiac death (SCD) due primarily to ventricular fibrillation claims 1.5 million lives worldwide each year. In 45%-50% of cases, it is the first manifestation of underlying heart disease. Traditional risk factors including smoking, hypertension, age, sex, as well as depressed left ventricular ejection fraction lack sufficient sensitivity and specificity to forewarn of impending life-threatening arrhythmias. There has been a decades-long search for electrocardiographic (ECG) markers of SCD risk. Several interval-based indices such as QT dispersion and Tpeak-Tend interval held initial promise but ultimately yielded mixed results. Recently, the focus has been on interlead heterogeneity of R- and T-wave morphology. The new approaches have involved advanced analytical tools including vectorcardiographic techniques and second central moment analysis of QRS-aligned templates to quantify heterogeneity of depolarization and repolarization waveforms. The results of current studies appear to be robust and worthy of further exploration. This review examines the electrophysiological underpinnings of heterogeneity-based risk assessment and provides an update of clinical techniques. We also discuss future directions whereby tracking heterogeneity may help to disclose latent risk for SCD not only in ECG recordings made at rest but also during ambulatory ECG monitoring and exercise tolerance testing.
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Affiliation(s)
- Richard L Verrier
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Heikki Huikuri
- Research Unit of Internal Medicine, Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
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Bonomini MP, Arini PD. Modulation of spatial variance of ventricular repolarization after myocardial infarction. Biomed Signal Process Control 2017. [DOI: 10.1016/j.bspc.2017.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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31
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Fuller H, Justo F, Nearing BD, Kahlig KM, Rajamani S, Belardinelli L, Verrier RL. Eleclazine, a new selective cardiac late sodium current inhibitor, confers concurrent protection against autonomically induced atrial premature beats, repolarization alternans and heterogeneity, and atrial fibrillation in an intact porcine model. Heart Rhythm 2016; 13:1679-86. [DOI: 10.1016/j.hrthm.2016.04.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Indexed: 12/24/2022]
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Bayer JD, Lalani GG, Vigmond EJ, Narayan SM, Trayanova NA. Mechanisms linking electrical alternans and clinical ventricular arrhythmia in human heart failure. Heart Rhythm 2016; 13:1922-31. [PMID: 27215536 DOI: 10.1016/j.hrthm.2016.05.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Mechanisms of ventricular tachycardia (VT) and ventricular fibrillation (VF) in patients with heart failure (HF) are undefined. OBJECTIVE The purpose of this study was to elucidate VT/VF mechanisms in HF by using a computational-clinical approach. METHODS In 53 patients with HF and 18 control patients, we established the relationship between low-amplitude action potential voltage alternans (APV-ALT) during ventricular pacing at near-resting heart rates and VT/VF on long-term follow-up. Mechanisms underlying the transition of APV-ALT to VT/VF, which cannot be ascertained in patients, were dissected with multiscale human ventricular models based on human electrophysiological and magnetic resonance imaging data (control and HF). RESULTS For patients with APV-ALT k-score >1.7, complex action potential duration (APD) oscillations (≥2.3% of mean APD), rather than APD alternans, most accurately predicted VT/VF during long-term follow-up (+82%; -90% predictive values). In the failing human ventricular models, abnormal sarcoplasmic reticulum (SR) calcium handling caused APV-ALT (>1 mV) during pacing with a cycle length of 550 ms, which transitioned into large magnitude (>100 ms) discordant repolarization time alternans (RT-ALT) at faster rates. This initiated VT/VF (cycle length <400 ms) by steepening apicobasal repolarization (189 ms/mm) until unidirectional conduction block and reentry. Complex APD oscillations resulted from nonstationary discordant RT-ALT. Restoring SR calcium to control levels was antiarrhythmic by terminating electrical alternans. CONCLUSION APV-ALT and complex APD oscillations at near-resting heart rates in patients with HF are linked to arrhythmogenic discordant RT-ALT. This may enable novel physiologically tailored, bioengineered indices to improve VT/VF risk stratification, where SR calcium handling and spatial apicobasal repolarization are potential therapeutic targets.
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Affiliation(s)
- J D Bayer
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University Foundation, Bordeaux, France; Institute of Mathematics of Bordeaux (U5251), University of Bordeaux, Bordeaux, France.
| | - G G Lalani
- Kaiser Permanente, San Diego, California
| | - E J Vigmond
- Electrophysiology and Heart Modeling Institute (LIRYC), Bordeaux University Foundation, Bordeaux, France; Institute of Mathematics of Bordeaux (U5251), University of Bordeaux, Bordeaux, France
| | | | - N A Trayanova
- Institute for Computational Medicine, Johns Hopkins University, Baltimore, Maryland
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Verrier RL, Fuller H, Justo F, Nearing BD, Rajamani S, Belardinelli L. Unmasking atrial repolarization to assess alternans, spatiotemporal heterogeneity, and susceptibility to atrial fibrillation. Heart Rhythm 2016; 13:953-61. [DOI: 10.1016/j.hrthm.2015.11.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Indexed: 11/24/2022]
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Kenttä TV, Nearing BD, Porthan K, Tikkanen JT, Viitasalo M, Nieminen MS, Salomaa V, Oikarinen L, Jula A, Kontula K, Newton-Cheh C, Huikuri HV, Verrier RL. Prediction of sudden cardiac death with automated high-throughput analysis of heterogeneity in standard resting 12-lead electrocardiograms. Heart Rhythm 2016; 13:713-20. [DOI: 10.1016/j.hrthm.2015.11.035] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Indexed: 10/22/2022]
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Verrier RL, Malik M. Quantitative T-wave alternans analysis for guiding medical therapy: an underexploited opportunity. Trends Cardiovasc Med 2014; 25:201-13. [PMID: 25541329 DOI: 10.1016/j.tcm.2014.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 10/09/2014] [Accepted: 10/09/2014] [Indexed: 11/18/2022]
Abstract
Reducing the toll of sudden cardiac death (SCD) remains a major challenge in cardiology, as it is the leading cause of adult mortality in the industrially developed world, claiming 310,000 lives annually in the United States alone. The main contemporary noninvasive index of cardiovascular risk, left ventricular ejection fraction (LVEF), has not proved adequately reliable, as the majority of individuals who die suddenly have relatively preserved cardiac mechanical function. Monitoring of T-wave alternans (TWA), a beat-to-beat fluctuation in ST-segment or T-wave morphology, is an attractive approach to risk stratification on both scientific and clinical grounds, as this ECG phenomenon has been shown using the FDA-cleared Spectral and Modified Moving Average methods to assess risk for cardiovascular mortality including SCD in studies enrolling >12,000 individuals with depressed or preserved LVEF. The evidence supporting TWA as a therapeutic target is reviewed.
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Affiliation(s)
- Richard L Verrier
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA.
| | - Marek Malik
- St. Paul׳s Cardiac Electrophysiology, University of London, and Imperial College, London, United Kingdom
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Bonatti R, Silva AFG, Batatinha JAP, Sobrado LF, Machado AD, Varone BB, Nearing BD, Belardinelli L, Verrier RL. Selective late sodium current blockade with GS-458967 markedly reduces ischemia-induced atrial and ventricular repolarization alternans and ECG heterogeneity. Heart Rhythm 2014; 11:1827-35. [DOI: 10.1016/j.hrthm.2014.06.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Indexed: 12/19/2022]
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Nearing BD, Verrier RL. Multilead template-derived residua of surface ECGS for quantitative assessment of arrhythmia risk. Ann Noninvasive Electrocardiol 2014; 20:273-81. [PMID: 25236344 DOI: 10.1111/anec.12205] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Contemporary electrocardiographic (ECG) markers including ventricular ectopy and arrhythmias have not proved reliable in risk assessment for life-threatening arrhythmias. METHODS We developed the "Multilead ECG Template-Derived Residua" approach to remove intrinsic morphologic differences and allow calculation of pathologic ECG heterogeneities among spatially separated leads. Prediction by R-wave and T-wave heterogeneity (RWH, TWH) analysis was tested in simulated and clinical ECGs. RESULTS An enabling description of the Residua algorithm is provided. Simulated ECGs with but not without Residua produced a linear relationship (correlation coefficient r(2) = 0.999) between input and output RWH and TWH values. In heart failure patients, Residua disclosed a marked crescendo in RWH from 164.1 ± 33.1 at baseline to 299.8 ± 54.5 μV and TWH from 134.5 ± 20.6 at baseline to 239.2 ± 37.0 μV at 30-45 minutes before the arrhythmia (both, P < 0.05), which remained elevated until arrhythmia onset. Without Residua, mean RWH and TWH were elevated at 1061.0 ± 222.9 and 882.5 ± 375.2 μV, respectively, throughout the recording and were not different prior to ventricular tachycardia onset. CONCLUSIONS Calculation of ECG-template derived Residua provides a highly accurate means for assessing arrhythmia risk from standard ECGs. Potential widespread applications include resting diagnostic 12-lead, ambulatory, and exercise ECGs, electrophysiologic study laboratory recordings, and implantable devices.
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Affiliation(s)
- Bruce D Nearing
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard-Thorndike Electrophysiology Institute, Harvard Medical School, Boston, MA
| | - Richard L Verrier
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard-Thorndike Electrophysiology Institute, Harvard Medical School, Boston, MA
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Rizas KD, Nieminen T, Barthel P, Zürn CS, Kähönen M, Viik J, Lehtimäki T, Nikus K, Eick C, Greiner TO, Wendel HP, Seizer P, Schreieck J, Gawaz M, Schmidt G, Bauer A. Sympathetic activity-associated periodic repolarization dynamics predict mortality following myocardial infarction. J Clin Invest 2014; 124:1770-80. [PMID: 24642467 DOI: 10.1172/jci70085] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 01/16/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Enhanced sympathetic activity at the ventricular myocardium can destabilize repolarization, increasing the risk of death. Sympathetic activity is known to cluster in low-frequency bursts; therefore, we hypothesized that sympathetic activity induces periodic low-frequency changes of repolarization. We developed a technique to assess the sympathetic effect on repolarization and identified periodic components in the low-frequency spectral range (≤0.1 Hz), which we termed periodic repolarization dynamics (PRD). METHODS We investigated the physiological properties of PRD in multiple experimental studies, including a swine model of steady-state ventilation (n=7) and human studies involving fixed atrial pacing (n=10), passive head-up tilt testing (n=11), low-intensity exercise testing (n=11), and beta blockade (n=10). We tested the prognostic power of PRD in 908 survivors of acute myocardial infarction (MI). Finally, we tested the predictive values of PRD and T-wave alternans (TWA) in 2,965 patients undergoing clinically indicated exercise testing. RESULTS PRD was not related to underlying respiratory activity (P<0.001) or heart-rate variability (P=0.002). Furthermore, PRD was enhanced by activation of the sympathetic nervous system, and pharmacological blockade of sympathetic nervous system activity suppressed PRD (P≤0.005 for both). Increased PRD was the strongest single risk predictor of 5-year total mortality (hazard ratio 4.75, 95% CI 2.94-7.66; P<0.001) after acute MI. In patients undergoing exercise testing, the predictive value of PRD was strong and complementary to that of TWA. CONCLUSION We have described and identified low-frequency rhythmic modulations of repolarization that are associated with sympathetic activity. Increased PRD can be used as a predictor of mortality in survivors of acute MI and patients undergoing exercise testing. TRIAL REGISTRATION ClinicalTrials.gov NCT00196274. FUNDING This study was funded by Angewandte Klinische Forschung, University of Tübingen (252-1-0).
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Verrier RL, Malik M. Electrophysiology of T-wave alternans: Mechanisms and pharmacologic influences. J Electrocardiol 2013; 46:580-4. [DOI: 10.1016/j.jelectrocard.2013.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Indexed: 12/31/2022]
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Verrier RL, Kumar K, Nieminen T, Belardinelli L. Mechanisms of ranolazine's dual protection against atrial and ventricular fibrillation. Europace 2013; 15:317-24. [PMID: 23220484 PMCID: PMC3578672 DOI: 10.1093/europace/eus380] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 10/22/2012] [Indexed: 12/19/2022] Open
Abstract
Coronary artery disease and heart failure carry concurrent risk for atrial fibrillation and life-threatening ventricular arrhythmias. We review evidence indicating that at therapeutic concentrations, ranolazine has potential for dual suppression of these arrhythmias. Mechanisms and clinical implications are discussed.
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Affiliation(s)
- Richard L Verrier
- Division of Cardiovascular Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215-3908, USA.
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VERRIER RICHARDL, NEARING BRUCED, GHANEM RAJAN, OLSON RACHELE, GARBERICH ROSSF, KATSIYIANNIS WILLIAMT, GORNICK CHARLESC, TANG CHUENY, HENRY TIMOTHYD. Elevated T-Wave Alternans Predicts Nonsustained Ventricular Tachycardia in Association with Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction (STEMI) Patients. J Cardiovasc Electrophysiol 2013; 24:658-63. [DOI: 10.1111/jce.12102] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 12/18/2012] [Accepted: 12/21/2012] [Indexed: 12/24/2022]
Affiliation(s)
- RICHARD L. VERRIER
- Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts USA
| | - BRUCE D. NEARING
- Beth Israel Deaconess Medical Center; Harvard Medical School; Boston Massachusetts USA
| | | | - RACHEL E. OLSON
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital; Minneapolis Minnesota USA
| | - ROSS F. GARBERICH
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital; Minneapolis Minnesota USA
| | - WILLIAM T. KATSIYIANNIS
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital; Minneapolis Minnesota USA
| | - CHARLES C. GORNICK
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital; Minneapolis Minnesota USA
| | - CHUEN Y. TANG
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital; Minneapolis Minnesota USA
| | - TIMOTHY D. HENRY
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital; Minneapolis Minnesota USA
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Tan AY, Verrier RL. The role of the autonomic nervous system in cardiac arrhythmias. HANDBOOK OF CLINICAL NEUROLOGY 2013; 117:135-45. [PMID: 24095122 DOI: 10.1016/b978-0-444-53491-0.00012-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Autonomic nervous system activity exerts potent and diverse effects on cardiac rhythm through elaborate neurocircuitry that is integrated at multiple levels. Adrenergic activity such as is associated with mental or physical stress or as a reflex response to myocardial ischemia is capable of generating significant rhythm abnormalities including ventricular fibrillation, the arrhythmia responsible for sudden cardiac death. With respect to the ventricles, vagus nerve activity is generally antiarrhythmic as it inhibits the profibrillatory effects of sympathetic nerve activation, whereas atrial arrhythmias generally derive from heightened levels of both vagus and sympathetic nerve activity. Containment of neural influences by pharmacological and electrical targeted neuromodulation is being pursued as an antiarrhythmic modality.
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Affiliation(s)
- Alex Y Tan
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Low doses of ranolazine and dronedarone in combination exert potent protection against atrial fibrillation and vulnerability to ventricular arrhythmias during acute myocardial ischemia. Heart Rhythm 2013; 10:121-7. [DOI: 10.1016/j.hrthm.2012.09.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Indexed: 12/19/2022]
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Nearing BD, Mittleman MA, Josephson ME, Verrier RL, Wellenius GA, Burger AJ. Response to Letter Regarding Article, “Crescendo in Depolarization and Repolarization Heterogeneity Heralds Development of Ventricular Tachycardia in Hospitalized Patients With Decompensated Heart Failure”. Circ Arrhythm Electrophysiol 2012. [DOI: 10.1161/circep.112.971952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bruce D. Nearing
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Mark E. Josephson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Richard L. Verrier
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Gregory A. Wellenius
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, Brown University, Providence RI
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Nearing BD, Wellenius GA, Mittleman MA, Josephson ME, Burger AJ, Verrier RL. Crescendo in depolarization and repolarization heterogeneity heralds development of ventricular tachycardia in hospitalized patients with decompensated heart failure. Circ Arrhythm Electrophysiol 2011; 5:84-90. [PMID: 22157521 DOI: 10.1161/circep.111.965434] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A critical need exists for reliable warning markers of in-hospital life-threatening arrhythmias. We used a new quantitative method to track interlead heterogeneity of depolarization and repolarization to detect premonitory changes before ventricular tachycardia (VT) in hospitalized patients with acute decompensated heart failure. METHODS AND RESULTS Ambulatory ECGs (leads V(1), V(5), and aVF) recorded before initiation of drug therapy from patients enrolled in the PRECEDENT (Prospective Randomized Evaluation of Cardiac Ectopy with Dobutamine or Nesiritide Therapy) trial were analyzed. R-wave heterogeneity (RWH) and T-wave heterogeneity (TWH) were assessed by second central moment analysis and T-wave alternans (TWA) by modified moving average analysis. Of 44 patients studied, 22 had experienced episodes of VT (≥4 beats at heart rates >100 beats/min) following ≥120 minutes of stable sinus rhythm, and 22 were age- and sex-matched patients without VT. TWA increased from 18.6±2.1 μV (baseline, mean±SEM) to 27.9±4.6 μV in lead V(5) at 15 to 30 minutes before VT (P<0.05) and remained elevated until the arrhythmia occurred. TWA results in leads V(1) and aVF were similar. RWH and TWH were elevated from 164.1±33.1 and 134.5±20.6 μV (baseline) to 299.8±54.5 and 239.2±37.0 μV at 30 to 45 minutes before VT (P<0.05), respectively, preceding the crescendo in TWA by 15 minutes. Matched patients without VT did not display elevated RWH (185.5±29.4 μV) or TWH (157.1±27.2 μV) during the 24-hour period. CONCLUSIONS This investigation is the first clinical demonstration of the potential utility of tracking depolarization and repolarization heterogeneity to detect crescendos in electrical instability that could forewarn of impending nonsustained VT. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00270400.
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Affiliation(s)
- Bruce D Nearing
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215-3908, USA
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Verrier RL, Klingenheben T, Malik M, El-Sherif N, Exner DV, Hohnloser SH, Ikeda T, Martínez JP, Narayan SM, Nieminen T, Rosenbaum DS. Microvolt T-wave alternans physiological basis, methods of measurement, and clinical utility--consensus guideline by International Society for Holter and Noninvasive Electrocardiology. J Am Coll Cardiol 2011; 58:1309-24. [PMID: 21920259 DOI: 10.1016/j.jacc.2011.06.029] [Citation(s) in RCA: 286] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Revised: 06/10/2011] [Accepted: 06/13/2011] [Indexed: 10/17/2022]
Abstract
This consensus guideline was prepared on behalf of the International Society for Holter and Noninvasive Electrocardiology and is cosponsored by the Japanese Circulation Society, the Computers in Cardiology Working Group on e-Cardiology of the European Society of Cardiology, and the European Cardiac Arrhythmia Society. It discusses the electrocardiographic phenomenon of T-wave alternans (TWA) (i.e., a beat-to-beat alternation in the morphology and amplitude of the ST-segment or T-wave). This statement focuses on its physiological basis and measurement technologies and its clinical utility in stratifying risk for life-threatening ventricular arrhythmias. Signal processing techniques including the frequency-domain Spectral Method and the time-domain Modified Moving Average method have demonstrated the utility of TWA in arrhythmia risk stratification in prospective studies in >12,000 patients. The majority of exercise-based studies using both methods have reported high relative risks for cardiovascular mortality and for sudden cardiac death in patients with preserved as well as depressed left ventricular ejection fraction. Studies with ambulatory electrocardiogram-based TWA analysis with Modified Moving Average method have yielded significant predictive capacity. However, negative studies with the Spectral Method have also appeared, including 2 interventional studies in patients with implantable defibrillators. Meta-analyses have been performed to gain insights into this issue. Frontiers of TWA research include use in arrhythmia risk stratification of individuals with preserved ejection fraction, improvements in predictivity with quantitative analysis, and utility in guiding medical as well as device-based therapy. Overall, although TWA appears to be a useful marker of risk for arrhythmic and cardiovascular death, there is as yet no definitive evidence that it can guide therapy.
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Affiliation(s)
- Richard L Verrier
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Kwofie MA, Chaudhary AK, Martins JB. Association among intracardiac T-wave alternans, ischemia, and spontaneous ventricular arrhythmias after coronary artery occlusion in a canine model. Transl Res 2011; 158:265-72. [PMID: 22005265 DOI: 10.1016/j.trsl.2011.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 07/03/2011] [Accepted: 07/06/2011] [Indexed: 10/18/2022]
Abstract
T-wave alternans (TWA) has been investigated as a marker for susceptibility to lethal ventricular arrhythmia. In this article, we studied intracardiac TWA and ischemia as predictors of spontaneous ventricular tachycardia (VT) or ventricular fibrillation (VF) in a canine model of coronary artery occlusion (CAO). Anesthetized, open-chest dogs were studied. Electrograms from intracardiac bipolar electrodes (IBEs) were assessed for TWA and spontaneous VT or VF. TWA was defined on IBE as T wave voltage change on every other complex. In each heart, we examined 62 electrograms measured in the risk zone and surrounding normal sites, filtered from 3 to 1300 Hz. Ischemia was measured as percent of all IBE recorded that had QRS voltage drop >45%. Mapping localized the three-dimensional origin of spontaneous VT or VF. The data from dogs with VF (n = 5), VT (n = 8), or controls (no VT or VF, n = 8) were analyzed before left CAO, at the 20th min after CAO and times immediately preceding VT and VF. We found a correlation between intracardiac TWA and ischemia. More importantly, increases in intracardiac TWA peaked immediately preceding spontaneous VF and VT and were significantly higher compared to controls at comparable times. At VT/VF origins and adjacent sites, the mean TWA magnitude and discordance of TWA distinguished between VT/VF and controls at comparable times but not between VT and VF or between reentry and focal mechanisms. TWA was more common than ischemia at VT/VF origins. In summary, changes in intracardiac TWA and ischemia correlate with impending spontaneous VT/VF in a clinically applicable canine model of CAO.
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Affiliation(s)
- Michael A Kwofie
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Iowa College of Medicine and Veterans Administration Medical Center, Iowa City, USA
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Strzelczyk A, Adjei P, Scott CA, Bauer S, Rosenow F, Walker MC, Surges R. Postictal increase in T-wave alternans after generalized tonic-clonic seizures. Epilepsia 2011; 52:2112-7. [DOI: 10.1111/j.1528-1167.2011.03266.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Antifibrillatory effect of ranolazine during severe coronary stenosis in the intact porcine model. Heart Rhythm 2010; 8:608-14. [PMID: 21094698 DOI: 10.1016/j.hrthm.2010.11.029] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 11/16/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Clinical evidence suggests that the antianginal agent ranolazine has antiarrhythmic properties, but its effects on vulnerability to ventricular fibrillation (VF) and T-wave alternans (TWA) during coronary artery stenosis have not been measured. OBJECTIVE We investigated whether the antiarrhythmic effect of ranolazine during acute coronary stenosis could be quantified by measuring VF threshold and TWA magnitude. METHODS Electrode catheters placed in the left ventricular apex were used to determine VF threshold during ventricular pacing at 130 beats/min, and TWA was quantified from epicardial electrograms using modified moving average method (N = 18). Left anterior descending coronary flow was reduced with a balloon occluder by 75% for 10 minutes. The I(Kr) blocker E-4031 was used to distinguish effects of late I(Na) and I(Kr) inhibition by ranolazine. RESULTS Before stenosis, ranolazine and E-4031 increased VF threshold from 32 ± 4 mA to 46 ± 4 mA (mean ± SEM), P = .02, and from 33 ± 5 mA to 40 ± 9 mA, P = .02, respectively. During stenosis, ranolazine increased VF threshold from 19 ± 2 mA to 33 ± 3 mA (P = .02), whereas E-4031 decreased VF threshold from 21 ± 3 mA to 15 ± 3 mA (P = .02). The ischemia-induced increase in TWA was suppressed by ranolazine but not by E-4031, consistent with effects of these agents on VF threshold. CONCLUSION Ranolazine exerts significant antifibrillatory effects during coronary stenosis through direct effects on cardiac electrical properties independent of coronary flow. Ranolazine's antifibrillatory action during myocardial ischemia does not appear to be mediated by blockade of I(Kr) but rather by inhibition of late I(Na). TWA changes paralleled vulnerability to VF as indicated by VF threshold testing.
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Leino J, Verrier RL, Minkkinen M, Lehtimäki T, Viik J, Lehtinen R, Nikus K, Kööbi T, Turjanmaa V, Kähönen M, Nieminen T. Importance of regional specificity of T-wave alternans in assessing risk for cardiovascular mortality and sudden cardiac death during routine exercise testing. Heart Rhythm 2010; 8:385-90. [PMID: 21056698 DOI: 10.1016/j.hrthm.2010.11.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 11/01/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND T-wave alternans (TWA) indicates increased risk for life-threatening arrhythmias. However, the regional distribution and predictivity of TWA among precordial leads remain unknown. OBJECTIVE We analyzed the magnitude and prognostic power of TWA in precordial leads separately and in combination during routine exercise stress testing in the largest TWA study conducted to date. METHODS The Finnish Cardiovascular Study (FINCAVAS) enrolled consecutive patients (n = 3,598, 56 ± 13 [mean ± standard deviation] years old, 2,164 men, 1,434 women) with a clinically indicated exercise test with bicycle ergometer. TWA was analyzed with the time-domain modified moving average method. RESULTS During a follow-up of 55 months (interquartile range of 35-78 months), 231 patients died; 97 deaths were cardiovascular, and 46 were classified as sudden cardiac deaths (SCDs). In Cox analysis after adjustment for common coronary risk factors, each 20-μV increase in TWA in leads V1-V6 multiplied the hazard ratio for cardiovascular mortality by 1.486-fold (95% confidence interval [CI] 1.127-1.952; P = .005). Each 20-μV increase in TWA in lead V5 amplified the hazard ratio for cardiovascular mortality by 1.545 (95% CI 1.150-2.108; P = .004) and for SCD by 1.576 (95% CI 1.041-2.412; P = .033). CONCLUSIONS Maximum TWA monitored from anterolateral precordial lead V5 is the strongest predictor of cardiovascular mortality and SCD during routine exercise testing in our analysis. Higher TWA values indicate greater cardiovascular mortality and SCD risk, supporting the concept that quantification of TWA should receive more attention.
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