Microvolt T-wave alternans and autonomic nervous system parameters can be helpful in the identification of low-arrhythmic risk patients with ischemic left ventricular systolic dysfunction

Abstract

IntroductionThe role of implantable cardioverter-defibrillator (ICD) placement in the primary prevention of sudden cardiac death (SCD) in all consecutive patients with left ventricular ejection fraction (LVEF) ≤ 35% is still a matter of hot debate due to the fact that the population of these patients is highly heterogeneous in terms of the SCD risk. Nevertheless, reduced LVEF is still the only established criterion during qualification of patients for ICD implantation in the primary prevention of SCD, therefore identification of persons with particularly high risk among patients with LVEF ≤35% is currently of lesser importance. More important seems to be the selection of individuals with relatively low risk of SCD in whom ICD implantation can be safely postponed. The aim of the study was to determine whether well-known, non-invasive parameters, such as microvolt T-wave alternans (MTWA), baroreflex sensitivity (BRS) and short-term heart rate variability (HRV), can be helpful in the identification of low-arrhythmic risk patients with ischemic left ventricular systolic dysfunction.MethodsIn 141 patients with coronary artery disease and LVEF ≤ 35%, MTWA testing, as well as BRS and short-term HRV parameters, were analysed. During 34 ± 13 months of follow-up 37 patients had arrhythmic episode (EVENT): SCD, non-fatal sustained ventricular arrhythmia (ventricular tachycardia [VT] or ventricular fibrillation [VF]), or adequate high-voltage ICD intervention (shock) due to a rapid ventricular arrhythmia ≥200/min. LVEF, non-negative MTWA (MTWA_non-neg), BRS and low frequency power in normalized units (LFnu) turned out to be associated with the incidence of EVENT in univariate Cox analysis. The cut-off values for BRS and LFnu that most accurately distinguished between patients with and without EVENT were 3 ms/mmHg and 23, respectively. The only variable that provided 100% negative predictive value (NPV) for EVENT was negative MTWA result (MTWA_neg), but solely for initial 12 months of the follow-up; the NPVs for other potential predictors of the EVENT were lower. The cut-off values for BRS and LFnu that provide 100% NPV for EVENT during 12 and 24 months were higher: 6.0 ms/mmHg and 73 respectively, but the gain in the NPV occurred at an expense of the number of identified patients. However, the number of identified non-risk patients turned out to be higher when the predictive model included MTWA_neg and the lower cut-off values for ANS parameters: 100% NPV for 12 and 24 months of follow-up was obtained for combination MTWA_neg and BRS ≥ 3 ms/mmHg, for combination MTWA_neg and LFnu ≥ 23 100% NPV was obtained for 12 months.ConclusionWell-known, non-invasive parameters, such as MTWA, BRS and short-term HRV indices may be helpful in the identification of individuals with a relatively low risk of malignant ventricular arrhythmias among patients with ischemic left ventricular systolic dysfunction; in such persons, implantation of ICD could be safely postponed.

Could autonomic nervous system parameters be still helpful in identifying patients with left ventricular systolic dysfunction at the highest risk of all-cause mortality?

“…In two recent studies [ 27 , 28 ], the usefulness of BRS and short-term HRV in prognosis, an increased risk of hospitalization due to HF decompensation [ 27 ], and identification of low-arrhythmic risk patients [ 28 ] was discovered. It needs to be noted, that cut-off values for BRS established in the abovementioned [ 27 , 28 ], and other studies [ 15 , 16 , 31 – 33 ], are similar, at well-known 3.0 ms/mmHg cut-off on BRS estimates, which presents, according to Gouveia et al [ 32 ], a natural partition of HF patients at risk.…”

“…Autonomic nervous system tests were performed according to the protocol precisely described in our previous studies [ 27 , 28 ] with the use of Mingograf 720C for ECG and Finapres 2300 (Ohmeda) for beat-to-beat non-invasive arterial blood pressure, which was recorded continuously for 8 min, but in comparison to abovementioned studies [ 27 , 28 ] during breathing with a controlled interval (0.25 Hz). Data received were converted from analog to digital signals, processed with dedicated software [ 29 ] and analyzed according to the protocol [ 15 , 30 ].…”

“…Data received were converted from analog to digital signals, processed with dedicated software [ 29 ] and analyzed according to the protocol [ 15 , 30 ]. BRS (ms/mmHg) was computed by spectral analysis exactly as it was previously described [ 27 , 28 ]. Furthermore, routine HRV indices: low-frequency (LF) to high-frequency (HF) ratio (LF/HF), relative spectral powers in LF (LFnu expressed in normalized units), as well as time-domain HRV parameters (standard deviation of normal-to-normal RR intervals [SDNN], the square root of the mean of squared differences between successive intervals [RMSSD], and the percentage of adjacent RR intervals differing by more than 50 ms [pNN50]) were analyzed [ 16 ].…”

Sudden Cardiac Death Prediction in Chronic Heart Failure Patients by Periodic Repolarization Dynamics

“…An interesting feature of this research is that PRD was calculated in 20-minute resting ECG recordings, thus facilitating generalization of PRD evaluation for risk stratification purposes. Other ECG indices, such as heart rate turbulence, deceleration capacity [18] or microvolt T wave alternans [5] are commonly measured from ambulatory ECG recordings or using specific protocols like stress tests.…”

“…A number of non-invasive markers measured from the electrocardiogram (ECG) have been proposed for PFD and SCD risk stratification in CHF. Among others, QT dispersion [3], Tpeak-to-Tend interval [4] and T wave alternans [5] have been evaluated. Periodic Repolarization Dynamics (PRD) has been recently proposed to assess sympathetic modulation of ventricular repolarization by measuring low-frequency (below 0.1 Hz) oscillations in the T wave vector [6].…”