Exercise-induced T-wave alternans as a marker of high risk in patients with hypertrophic cardiomyopathy

Microvolt-level T-wave alternans (alternating morphology from beat to beat) during atrial pacing and exercise may predict ventricular tachycardia (VT) and fibrillation (VF) in ischemic heart disease, We tested whether such alternans during exercise could identify high-risk patients with hypertrophic cardiomyopathy (HCM). We studied 14 HCM patients and 9 normal control subjects for T-wave alternans using the CH2000 system with 7 multisegment electrodes in a Frank orthogonal (XYZ) configuration. Bicycle ergometer exercise was used to increase the heart rate (HR) to 95-110 beats/min. Seven patients were at high risk for ventricular arrhythmias (1 with sustained VT, 3 with abnormal paced ventricular electrograms as seen in VF survivors, and 3 with nonsustained VT and/or an adverse family history), and the other 7 were at low risk. T-wave alternans was present if alternans >1.9 mu V was consistently present with the HR in excess of a patient-specific HR threshold, Alternans was found in 5 of 7 high-risk patients (71%) vs none of 7 low-risk patients or 9 control subjects (p<0.025 and p<0.01, respectively). Notably, all 3 patients with sustained VT or abnormal ventricular electrograms showed alternans, Thus, high-risk patients with HCM often show T-wave alternans, Microvolt-level alternans during exercise may be a useful marker for ventricular arrhythmic risk in patients with HCM.