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N Engl J Med. 1994 Jan 27;330(4):235-41.

Electrical alternans and vulnerability to ventricular arrhythmias.

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Cardiac Unit, Massachusetts General Hospital, Boston.



Although electrical alternans (alternating amplitude from beat to beat on the electrocardiogram) has been associated with ventricular arrhythmias in many clinical settings, its physiologic importance and prognostic implications remain unknown.


To test the hypothesis that electrical alternans is a marker of vulnerability to ventricular arrhythmias, we developed a technique to detect subtle alternation in the morphologic features of the electrocardiogram (which would not be detectable by visual inspection of the electrocardiogram). In a group of 83 patients referred for diagnostic electrophysiologic testing, we prospectively examined whether levels of alternans predicted vulnerability to arrhythmias as defined by the outcome of electrophysiologic testing and arrhythmia-free survival.


Sustained ventricular arrhythmias were induced during electrophysiologic testing in 32 of the patients (39 percent). In this group, low-level electrical alternans (a beat-to-beat change in amplitude of < 15 microV) was detected over a broad range of physiologic heart rates (from 95 to 150 beats per minute) and primarily involved the ST segment and the T wave (i.e., the phase of repolarization). Alternans during repolarization was a significant and independent predictor of inducible arrhythmias on electrophysiologic testing (sensitivity, 81 percent; specificity, 84 percent; relative risk, 5.2). Of 66 patients followed for up to 20 months, 13 had arrhythmic events. Alternans affecting the T wave and inducibility of ventricular arrhythmias were significant and essentially equivalent predictors of survival without arrhythmia (P < 0.001). Actuarial survival without arrhythmia at 20 months was significantly lower among the patients with T-wave alternans (19 percent) than among the patients without T-wave alternans (94 percent).


Electrical alternans affecting the ST segment and T wave is common among patients at increased risk for ventricular arrhythmias. Subtle electrical alternans on the electrocardiogram may serve as a noninvasive marker of vulnerability to ventricular arrhythmias.

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