Beat-to-beat alternans

Article information

Korean J Intern Med. 2025;.kjim.2024.372

Publication date (electronic) : 2025 May 21

doi : https://doi.org/10.3904/kjim.2024.372

¹Division of Cardiology, Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea

²Division of Cardiology, Section of Electrophysiology, University of California San Francisco, San Francisco, CA, USA

Correspondence to Melvin M. Scheinman, M.D., F.H.R.S. Division of Cardiology, Section of Electrophysiology, University of California, 500 Parnassus Avenue, MUE-434, Box 1354, San Francisco, CA 94117, USA Tel: +1-425-307-5251, Fax: +1-415-476-6260 E-mail: Melvin.Scheinman@ucsf.edu

Received 2024 November 20; Revised 2024 December 11; Accepted 2025 January 3.

A 78-year-old male treated for pneumonia was referred to the cardiology department after post-cardiopulmonary resuscitation due to torsades de pointes (TdP) (Fig. 1A). The laboratory findings revealed an increased N-terminal probrain natriuretic peptide level of 569 pg/mL (normal range < 125 pg/mL) and an increased troponin-I level of 0.47 ng/mL (normal range < 0.04 ng/mL). With the cessation of ciprofloxacin, after an electrolyte correction and lidocaine infusion, the TdP episodes were no longer observed. Four days later, a follow-up electrocardiogram (ECG) (Fig. 1B) revealed a beat-to-beat macroscopic T-wave alternans (TWA) with an alternating change in the QT interval. Echocardiography revealed apical ballooning compatible with takotsubo cardiomyopathy (TCM). Considering his precarious condition, coronary angiography was not performed. Despite intensive combination antibiotic therapy, his pneumonia progressed, and he died.

Figure 1.

(A) The electrocardiogram strip shows a prolonged QT interval and frequent premature ventricular contractions (blue dots), which set up long-short sequences that initiated episodes of torsades. (B) The follow-up electrocardiogram revealed giant negative T-waves with a markedly prolonged QT interval. Note the beat-to-beat macroscopic T-wave alternans with an alternating change in the QT interval (red and blue bars).

TWA is a beat-to-beat alternation in the amplitude and/or shape of the T-waves on the surface ECG. These fluctuations of the T-wave are primary and unrelated to alternations in the other components of the ECG (i.e., QRS alternans). TWA has been described in patients with pathological conditions such as myocardial ischemia, long-QT syndrome, electrolyte imbalances, and TCM [1]. Also, TWA is closely associated with the development of ventricular arrhythmias [2].

This patient displayed interesting ECG findings. He initially presented with TdP, which was likely a result of the ciprofloxacin and abnormal electrolytes. After a correction of the above, he developed marked TWA, which was likely related to TCM. A likely mechanism of the TCM is catecholamine-mediated myocardial stunning. Catecholamines induce myocardial injury via a calcium overload [3], which may be related to alternans of cytosolic calcium [4]. Alternans of cytosolic calcium also cause fluctuations in the action potential duration; hence, TWA can be caused by a calcium accumulation [5,6] and is linked to mechanical alternans [7].

Notes

CRedit authorship contributions

Chan-Hee Lee: resources, data curation, writing - review & editing, supervision; Melvin M. Scheinman: conceptualization, writing - review & editing, supervision

Conflicts of interest

The authors disclose no conflicts.

Funding

None

References

1. Warraich HJ, Buxton AE, Kociol RD. Macroscopic T-wave alternans in a patient with takotsubo cardiomyopathy and QT prolongation. Heart Rhythm 2014;11:1848–1849.

2. Cutler MJ, Rosenbaum DS. Explaining the clinical manifestations of T wave alternans in patients at risk for sudden cardiac death. Heart Rhythm 2009;6(3 Suppl):S22–S28.

3. Mann DL, Kent RL, Parsons B, Cooper G 4th. Adrenergic effects on the biology of the adult mammalian cardiocyte. Circulation 1992;85:790–804.

4. Hojo R, Fukamizu S, Kitamura T, et al. Prominent J-wave and T-wave alternans associated with mechanical alternans in a patient with takotsubo cardiomyopathy. J Arrhythm 2015;31:43–46.

5. Pruvot EJ, Katra RP, Rosenbaum DS, Laurita KR. Role of calcium cycling versus restitution in the mechanism of repolarization alternans. Circ Res 2004;94:1083–1090.

6. Bayer JD, Narayan SM, Lalani GG, Trayanova NA. Rate-dependent action potential alternans in human heart failure implicates abnormal intracellular calcium handling. Heart Rhythm 2010;7:1093–1101.

7. Selvaraj RJ, Suszko A, Subramanian A, Mak S, Wainstein R, Chauhan VS. Microscopic systolic pressure alternans in human cardiomyopathy: noninvasive evaluation of a novel risk marker and correlation with microvolt T-wave alternans. Heart Rhythm 2011;8:236–243.

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