The Influence of Advanced Congestive Heart Failure on Pulsus Alternans

Abstract

Evidence is presented which indicates that in certain instances pulsus alternans may be abolished or diminished in the presence of advanced congestive heart failure. The observations suggest that in severe congestive failure the ventricular filling pressure may increase to the point where it causes the diastolic stretch of the left ventricle to be more equal from one beat to the next. This in turn would bring about more uniform systolic ejections and hence ventricular alternation would disappear or be lessened in degree. P ULSUS ALTERNANS is considered a grave sign of heart disease, indicating myocardial insufficiency.1 Recent observations indicate that this phenomenon can be profoundly influenced by changes in the venous return to the heart. During the past two years we have encountered 12 patients with pulsus alternans and have noted that in certain instances advanced congestive failure may also influence pulsus alternans. We wish to report detailed studies of three of these patients. MATERIAL AND METHODSThree patients, all of whom showed pulsus alternans initially and who were on accepted treatment for cardiac failure were observed. One, who had rheumatic aortic insufficiency-, was in heart failure following treated subacute bacterial endocarditis. Two observations were made on this man; the first, when he showed early signs and symptoms of left heart failure, and the second, w-hen he was in intractable congestive failure seven months later. The remaining two patients had hypertensive heart disease with severe congestive failure as evidenced by dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea, venous distention, liver engorgement and peripheral edema. After the pulsus alternans was demonstrated, both were taken off all treatment for heart failure and were put on an unrestricted sodium diet for a period of 7 to 10 days. They were followed both symptomatically and by weight. Repeated

Stability and instability of regulation of intracellular calcium

“…As mentioned above, alternans is associated with heart failure and ischaemia and this correlation is seen in animal studies (Dumitrescu et al 2002; Hata et al 1997; Qian et al 2001; Wu & Clusin, 1997) as well as in humans (Hata et al 1997; Kodama et al 2001 a , b ; Ryan et al 1955; Salerno et al 1986). It is not, however, obvious as to which of the many changes of Ca handling that occurs in failure is the cause of alternans, and we will return to this point below.…”

Sarcoplasmic Reticulum Calcium Content Fluctuation Is the Key to Cardiac Alternans

“…4 One abnormality of Ca 2ϩ handling is mechanical alternans where large and small contractions follow each other [5][6][7] due to alternation of systolic Ca 2ϩ . 8,9 Alternans is prominent in heart failure 5,10,11 and is induced by ischemia and acidosis. 7,12,13 Action potential alternans (T-wave alternans) predisposes to arrhythmias 14,15 and may be due to changes of Ca 2ϩ handling.…”

Hemodynamic rounds series II: Mitral stenosis and pulsus alternans

“…To my knowledge, pulsus alternans is an unusual phenomenon in mitral valve disease and especially in mitral stenosis [2][3][4][5]. Pulsus alternans is most commonly associated with decreased left ventricular function, a condition not present by ventriculography or echocardiog- raphy.…”