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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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Pereira Filho HG, Samesima N, Madaloso BA, de Oliveira Tobias NMM, Facin M, Pastore CA. Modified moving average methodology applied to the treadmill stress testing analysis of microvolt T-wave alternans. Sci Rep 2022; 12:22454. [PMID: 36575194 PMCID: PMC9794681 DOI: 10.1038/s41598-022-26535-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/15/2022] [Indexed: 12/28/2022] Open
Abstract
Sudden cardiac death is impactful. There has been an increase in the search for tools capable of identifying individuals who are most susceptible, such as the microvolt T-wave alternans. This study aims to analyze the applicability of the modified moving average methodology to obtain the microvolt T-wave alternans using treadmill specific protocols. Medical records of patients during the period August 2006-December 2014 were retrospectively analyzed. Five hundred and thirty nine exams were then included, divided into groups according to the protocol and updating factor used: Ellestad factor 8 or 32, Naughton factor 8 or 32. The topics for analysis were the alternans behavior, noise and confirmation according to the groups of leads analyzed (frontal, transversal and orthogonal planes). The greater microvolt T-wave alternans was found during the stress phase in most of the tests. Group Naughton 8 presented lower noise in this phase for the transverse and orthogonal planes (p = 0.0082 and p < 0.0001), with greater confirmation of frontal and orthogonal planes in comparison with group Ellestad 8 (p = 0.0002 and 0.0008). The results indicate the viability of simultaneous performance of the stress test and measurement of the T wave alternans with Naughton protocol with 1/8 updating factor.
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Affiliation(s)
- Horacio Gomes Pereira Filho
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
| | - Nelson Samesima
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
| | - Bruna Affonso Madaloso
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
| | - Nancy Maria Martins de Oliveira Tobias
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
| | - Mirella Facin
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
| | - Carlos Alberto Pastore
- grid.11899.380000 0004 1937 0722Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Unidade de Eletrocardiografia, Sao Paulo, SP 05403-900 Brazil
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You T, Luo C, Zhang K, Zhang H. Electrophysiological Mechanisms Underlying T-Wave Alternans and Their Role in Arrhythmogenesis. Front Physiol 2021; 12:614946. [PMID: 33746768 PMCID: PMC7969788 DOI: 10.3389/fphys.2021.614946] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/10/2021] [Indexed: 12/18/2022] Open
Abstract
T-wave alternans (TWA) reflects every-other-beat alterations in the morphology of the electrocardiogram ST segment or T wave in the setting of a constant heart rate, hence, in the absence of heart rate variability. It is believed to be associated with the dispersion of repolarization and has been used as a non-invasive marker for predicting the risk of malignant cardiac arrhythmias and sudden cardiac death as numerous studies have shown. This review aims to provide up-to-date review on both experimental and simulation studies in elucidating possible mechanisms underlying the genesis of TWA at the cellular level, as well as the genesis of spatially concordant/discordant alternans at the tissue level, and their transition to cardiac arrhythmia. Recent progress and future perspectives in antiarrhythmic therapies associated with TWA are also discussed.
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Affiliation(s)
- Tingting You
- Key Lab of Medical Electrophysiology, Ministry of Education, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China
| | - Cunjin Luo
- School of Computer Science and Electronic Engineering, University of Essex, Colchester, United Kingdom
| | - Kevin Zhang
- School of Medicine, Imperial College of London, London, United Kingdom
| | - Henggui Zhang
- Key Lab of Medical Electrophysiology, Ministry of Education, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China.,Department of Physics and Astronomy, University of Manchester, Manchester, United Kingdom
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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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Martin-Yebra A, Monasterio V, Cygankiewicz I, Bayes-de-Luna A, Caiani EG, Laguna P, Martinez JP. Post-Ventricular Premature Contraction Phase Correction Improves the Predictive Value of Average T-Wave Alternans in Ambulatory ECG Recordings. IEEE Trans Biomed Eng 2018; 65:635-644. [PMID: 29461965 DOI: 10.1109/tbme.2017.2711645] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We proposed and evaluated a method for correcting possible phase shifts provoked by the presence of ventricular premature contractions (VPCs) for a better assessment of T-wave alternans (TWA). Methods: First, we synthesized ECG signals with artificial TWA in the presence of different noise sources. Then, we assessed the prognostic value for sudden cardiac death (SCD) of the long-term average of TWA amplitude (the index of average alternans, ) in ambulatory ECG signals from congestive heart failure (CHF) and evaluated whether it is sensitive to the presence of VPCs. RESULTS The inclusion of the phase correction after VPC in the processing always improved estimation accuracy of the under different noisy conditions and regardless of the number of the VPCs included in the sequence. It also presented a positive impact on the prognostic value of with increased hazard ratios (from 17% to 29%, depending of the scenario) in comparison to the noninclusion of this step. CONCLUSION The proposed methodology for estimation, which corrects for the possible phase reversal on TWA after the presence of VPCs, represents a robust TWA estimation approach with a significant impact on the prognostic value of for SCD stratification in CHF patients. SIGNIFICANCE An accurate TWA estimation has a potential direct clinical impact on noninvasive SCD stratification, allowing better identification of patients at higher risk and helping clinicians in adopting the most appropriate therapeutic strategy.
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ECG Parameters for Malignant Ventricular Arrhythmias: A Comprehensive Review. J Med Biol Eng 2017; 37:441-453. [PMID: 28867990 PMCID: PMC5562779 DOI: 10.1007/s40846-017-0281-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/31/2016] [Indexed: 02/01/2023]
Abstract
Many studies showed electrocardiogram (ECG) parameters are useful for predicting fatal ventricular arrhythmias (VAs). However, the studies have several shortcomings. Firstly, all studies lack of effective way to present behavior of various ECG parameters prior to the occurrence of the VAs. Secondly, they also lack of discussion on how to consider the parameters as abnormal. Thirdly, the reports do not include approaches to increase the detection accuracy for the abnormal patterns. The purpose of this study is to address the aforementioned issues. It identifies ten ECG parameters from various sources and then presents a review based on the identified parameters. From the review, it has been found that the increased risk of VAs can be represented by presence and certain abnormal range of the parameters. The variation of parameters range could be influenced by either gender or age. This study also has discovered the facts that averaging, outliers elimination and morphology detection algorithms can contribute to the detection accuracy.
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Lewek J, Ptaszynski P, Klingenheben T, Cygankiewicz I. The clinical value of T-wave alternans derived from Holter monitoring. Europace 2016; 19:529-534. [DOI: 10.1093/europace/euw292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/19/2016] [Indexed: 11/12/2022] Open
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Abstract
Microvolt T-wave alternans (TWA), characterised as beat-to-beat fluctuation of T-wave amplitude and morphology, is an electrophysiological phenomenon associated clinically with impending ventricular arrhythmias and is an important marker of arrhythmia risk. Currently, two main methods for the detection of TWA exist, namely, the spectral method and the time-domain modified moving average method; both are discussed in this review. Microvolt TWA has been associated with cardiovascular mortality and sudden cardiac death in several clinical studies involving >14,000 subjects with reduced as well as preserved left ventricular function. Although TWA appears to be a useful marker of susceptibility for lethal ventricular arrhythmias and cardiovascular death, so far there is no sufficient evidence from randomised clinical trials to support its use in guiding therapy. However, several ongoing trials are expected to provide more information about the clinical use of TWA testing.
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Affiliation(s)
- Aapo L Aro
- Helsinki University Hospital, Helsinki, Finland
| | - Tuomas V Kenttä
- University Hospital of Oulu and University of Oulu, Oulu, Finland
| | - Heikki V Huikuri
- University Hospital of Oulu and University of Oulu, Oulu, Finland
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Guevara MR, Shrier A, Orlowski J, Glass L. George Ralph Mines (1886-1914): the dawn of cardiac nonlinear dynamics. J Physiol 2016; 594:2361-71. [PMID: 27126414 DOI: 10.1113/jp270891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 01/29/2016] [Indexed: 11/08/2022] Open
Affiliation(s)
- Michael R Guevara
- Department of Physiology, McGill University, Montreal, Quebec, Canada
| | - Alvin Shrier
- Department of Physiology, McGill University, Montreal, Quebec, Canada
| | - John Orlowski
- Department of Physiology, McGill University, Montreal, Quebec, Canada
| | - Leon Glass
- Department of Physiology, McGill University, Montreal, Quebec, Canada
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Electrocardiographic Predictors of Cardiovascular Mortality. DISEASE MARKERS 2015; 2015:727401. [PMID: 26257460 PMCID: PMC4519551 DOI: 10.1155/2015/727401] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 06/20/2015] [Accepted: 07/02/2015] [Indexed: 01/26/2023]
Abstract
Cardiovascular diseases are the main causes of mortality. Sudden cardiac death may also appear in athletes, due to underlying congenital or inherited cardiac abnormalities. The electrocardiogram is used in clinical practice and clinical trials, as a valid, reliable, accessible, inexpensive method. The aim of the present paper was to review electrocardiographic (ECG) signs associated with cardiovascular mortality and the mechanisms underlying those associations, providing a brief description of the main studies in this area, and consider their implication for clinical practice in the general population and athletes. The main ECG parameters associated with cardiovascular mortality in the present paper are the P wave (duration, interatrial block, and deep terminal negativity of the P wave in V1), prolonged QT and Tpeak-Tend intervals, QRS duration and fragmentation, bundle branch block, ST segment depression and elevation, T waves (inverted, T wave axes), spatial angles between QRS and T vectors, premature ventricular contractions, and ECG hypertrophy criteria.
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