15. Naunheim KS, Dean PA, Fiore AC, McBride LR, PenningtonDG, Kaiser GC, Willman VL, Barrier HB. Cardiac surgery in the octogenarian.Eur J Cardiothorac Surg 1990;41:130-135. 16. Tsai TP, Chaux A, Kass RM, Gray RJ, Matloff JM. Aortocoronary bypass surgery in septuagenariansand octogenarians.J Cardiouasc Surg (Torino) 1989;30:364-368. 17. Jeroudi MO, Kleiman NS, Minor ST, Hess KR, Lewis JM, Winters WL, Raizner AE. Percutaneoustransluminal coronary angioplasty in octogenarians. Ann Int Med 1990;113:423%428.
Prevalence and Significance Coronary Angioplasty
16. Kern MJ, Deligonul U, Galan K, Zelman R, Gabliani G, Bell ST, Bodet J, NaunheimK, VandormaelM. Percutaneoustransluminalcoronary angioplastyin octogenarians.Am J Cardiol 1988;61:457-458. 19. Weintraub WS, JonesEL, Craver J, Guyton R, Cohen CL. Determinantsof prolonged length of hospital stay after coronary bypass surgery. Circulation 198%80x276-284. 20. National Center for Health Statistics. Mortality. Washington,DC.: Public Health Service, 1990.(Vital Statistics of the United States, 1987,vol II, part A, section 6, page 6.)
of ST-Segment
Alternans
During
Ian C. Gilchrist. MD lectrical alternansis a phenomenonof alternating electrocardiographic morphology on an everyother-beat basis. ST-segment alternans is often seenin the animal laboratory with subtotal or transient coronary artery occlusion.l In humans it has been observedin a variety of settings,such as Prinzmetal’s angina and once during percutaneoustransluminal coronary angioplasty (PTCA).2 Although clinically rarely observed, ST-segment alternans has been correlated with subsequentmalignant arrhythmias and may be an important marker of electrically unstable myocardium.3 This study was performed to determine whether PTCAinduced transmural ischemia could reproducibly induce ST-segmentalternans and serveas a model for this syndrome.
E
and, when feasible, intracoronary blood pressure monitoring. More than 90% of the patients had Ll balloon inflation X0 seconds. Each patient’s record was reviewedfor target arteries, number and duration of balloon inflations, presence of ST-segment alternans, and complications. Five patients were observed to have ST-segment alternans. Their records were further reviewed for cardiac history, prior PTCA procedures, coronary anatomy and ventricular function, medications and electrolytes. The records were also reviewed for contrast agent use, angina1 symptoms, hemodynamic changes and sequence of electrocardiographic changes in relation to duration of balloon inflation. Clinical characteristics and pertinent data for the 5 Laboratory records of 407 consecutive patients un- patients with ST-segment alternans are listed in Tadergoing PTCA, with continuous electrocardiographble I. Four of these cases occurred of I95 angioplastic monitoring and recording of 22 standard leads ies of the left anterior descending artery, and 1 of 102 during balloon inflations, were evaluated. Lead selec- angioplasties of the left circumflex artery. No epition was based on the most likely ischemic zone dursodes of ST-segment alternans were seen in 110 aning PTCA. Most procedures were performed using gioplasties of the right coronary artery. ST-segment alternans never developed with C.55 seconds of arteristandard over-a-wire balloon techniques with arterial al occlusion. With repeated dilatations, ST-segment From the Division of Cardiology, The Milton S. Hershey Medical alternans was reproducible at about the same time of Center, PennsylvaniaState University, Hershey, Pennsylvania 17033. Manuscript received May 24, 1991; revised manuscript received and balloon occlusion. RR intervals and QRS morphologies were unchanged during periods of ST-segment acceptedJuly 26, 1991. TABLE
I Clinical Characteristics of Patients with ST-Segment Alternans During Coronary Angioplasty
Age lyr) & Sex
PTCA Artery
Collaterals
Diameter Narrowings in Other Coronary Arteries
1
71 M
2 3 4 5
74 M
LAD LAD LAD LC LAD
0 0 + 0 +
90%-D 1 60%-LC lOO%-LC 0 95%-LC
Pt. No.
71 F 57 M 69 M
*Persisted for 120 seconds, then developed into uniform ST elevation. D = ST-segment depression; Dl = first diagonal branch; E = ST-segment transluminal coronary angioplasty; - = no information available.
1534
elevation;
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 68
Onset of Alternans Isec)
E E E E D
55
95 60
120* 100 LAD = left anterior
Type of ST Change
descending
DECEMBER 1, 1991
artery;
Inflation Time bed
Angina1 Symptoms Moderate
180 180
Slight
420 360
Severe
180
Slight
LC = left circumflex
artery;
PTCA = percutaneous
FIGURE 1. An example of ST-segment altemansasrecorddfrompatient3on electrwardiiraphic lead V5 at 25 mm/s.
alternans (Figure 1). Pulsus alternans was not noted by either arterial or intracoronary blood pressure monitoring, whereas the perception of angina ranged from minimal to severe during the period of ST-segment alternans. All patients described in this report had normal electrolytes and QT intervals. All patients were pretreated with both nitrates and calcium antagonists (nifedipine or diltiazem). The procedures were performed with a variety of contrast agents (iohexal, and diatrizoate and ioxaglate meglumine sodiums). Patient 4 had previous PTCA at the same site without ST-segment alternans, but balloon inflation times then were 7The present report and other studies in humans2>4 have shown no hemodynamic alterations during ST-segment alternans. These findings need further confirmation with either echocardiographic or catheter tip transducer techniques.
ST-segment alternans in our patients occurred only during relatively prolongedballoon dilatations. This suggests that a threshold of ischemia may be required to induce ST-segmentalternans.Presenceof demonstrable collaterals in severalpatients, and their ability to tolerate prolonged balloon inflations, implies that ST-segment alternansmay be lessischemicin responsethan progressive ST-segment elevation. ST-segment alternans may be part of the continuum of ST-segment responsesto transmural myocardial ischemia. This hypothesisis supported by the observationof ST-segmentalternans progressingto uniform ST-segment elevation. This study suggeststhat ST-segment alternans is a relatively rare phenomenon during PTCA and occurs without significant sequelae.Extensive use of calcium antagonists in these patients may be suppressingthe manifestation of ST-segmentalternans.7Alternans may have been too localized to distinguish with standard electrocardiography. Monitoring 12-lead electrocardiograms, orthagonal leads, intracoronary electrodes or monophasicaction potentials may have yielded a greater prevalenceof this phenomenon. 1. H&r&n HK. Liebow IM. Electrical alternation in experimental coronary artery occlusion. Am J Physior 1950;160:366-374. 2. Joyal M, Feldman R, Pepine CJ. ST-segment alternans during percutaneous transluminal coronary angioplasty. Am J Cardiol 1984;54:915-916. 3. Salerno JA, Previtali M, Panciroli C, Klersy C, Chimienti M, Bonora MR, Marangoni E, Falcone C, Guasti L, Campana C, Rondanelli R. Ventricular arrhythmias during acute myocardial ischaemia in man. The role and significance of R-ST-T alternans and the prevention of ischaemic sudden death by medical treatment. Eur Heart J 1986;7A:63-75. 4. Sutton PMI, Taggart P, Lab M, Runnalls ME, O’Brien W, Treasure T. Alternans of epicardial repolarization as a localized phenomenon in man. Eur Heart J 1991;12:70-78. 5. Kleinfeld M, Stein E, Kossmann CE. Electrical alternans with emphasis on recent observations made by means of a single-cell electrical recording. Am Heart J 1963;65:495-500, 6. Roselle HA, Crampton RS, Case RB. Alternans of the deprased ST-segment during coronary insufficiency. Am J Cardiol 1966;18:200-207. 7. Hashimoto H, Suzuki K, Miyake S, Nakashima M. Effects of calcium antagonists on the electrical alternans of the ST segment and on associated mechanical alternans during acute coronary occlusion in dogs. Circulation 1983;68:667-672.
BRIEF REPORTS 1535
Prevalence and Significance Coronary Angioplasty
16. Kern MJ, Deligonul U, Galan K, Zelman R, Gabliani G, Bell ST, Bodet J, NaunheimK, VandormaelM. Percutaneoustransluminalcoronary angioplastyin octogenarians.Am J Cardiol 1988;61:457-458. 19. Weintraub WS, JonesEL, Craver J, Guyton R, Cohen CL. Determinantsof prolonged length of hospital stay after coronary bypass surgery. Circulation 198%80x276-284. 20. National Center for Health Statistics. Mortality. Washington,DC.: Public Health Service, 1990.(Vital Statistics of the United States, 1987,vol II, part A, section 6, page 6.)
of ST-Segment
Alternans
During
Ian C. Gilchrist. MD lectrical alternansis a phenomenonof alternating electrocardiographic morphology on an everyother-beat basis. ST-segment alternans is often seenin the animal laboratory with subtotal or transient coronary artery occlusion.l In humans it has been observedin a variety of settings,such as Prinzmetal’s angina and once during percutaneoustransluminal coronary angioplasty (PTCA).2 Although clinically rarely observed, ST-segment alternans has been correlated with subsequentmalignant arrhythmias and may be an important marker of electrically unstable myocardium.3 This study was performed to determine whether PTCAinduced transmural ischemia could reproducibly induce ST-segmentalternans and serveas a model for this syndrome.
E
and, when feasible, intracoronary blood pressure monitoring. More than 90% of the patients had Ll balloon inflation X0 seconds. Each patient’s record was reviewedfor target arteries, number and duration of balloon inflations, presence of ST-segment alternans, and complications. Five patients were observed to have ST-segment alternans. Their records were further reviewed for cardiac history, prior PTCA procedures, coronary anatomy and ventricular function, medications and electrolytes. The records were also reviewed for contrast agent use, angina1 symptoms, hemodynamic changes and sequence of electrocardiographic changes in relation to duration of balloon inflation. Clinical characteristics and pertinent data for the 5 Laboratory records of 407 consecutive patients un- patients with ST-segment alternans are listed in Tadergoing PTCA, with continuous electrocardiographble I. Four of these cases occurred of I95 angioplastic monitoring and recording of 22 standard leads ies of the left anterior descending artery, and 1 of 102 during balloon inflations, were evaluated. Lead selec- angioplasties of the left circumflex artery. No epition was based on the most likely ischemic zone dursodes of ST-segment alternans were seen in 110 aning PTCA. Most procedures were performed using gioplasties of the right coronary artery. ST-segment alternans never developed with C.55 seconds of arteristandard over-a-wire balloon techniques with arterial al occlusion. With repeated dilatations, ST-segment From the Division of Cardiology, The Milton S. Hershey Medical alternans was reproducible at about the same time of Center, PennsylvaniaState University, Hershey, Pennsylvania 17033. Manuscript received May 24, 1991; revised manuscript received and balloon occlusion. RR intervals and QRS morphologies were unchanged during periods of ST-segment acceptedJuly 26, 1991. TABLE
I Clinical Characteristics of Patients with ST-Segment Alternans During Coronary Angioplasty
Age lyr) & Sex
PTCA Artery
Collaterals
Diameter Narrowings in Other Coronary Arteries
1
71 M
2 3 4 5
74 M
LAD LAD LAD LC LAD
0 0 + 0 +
90%-D 1 60%-LC lOO%-LC 0 95%-LC
Pt. No.
71 F 57 M 69 M
*Persisted for 120 seconds, then developed into uniform ST elevation. D = ST-segment depression; Dl = first diagonal branch; E = ST-segment transluminal coronary angioplasty; - = no information available.
1534
elevation;
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 68
Onset of Alternans Isec)
E E E E D
55
95 60
120* 100 LAD = left anterior
Type of ST Change
descending
DECEMBER 1, 1991
artery;
Inflation Time bed
Angina1 Symptoms Moderate
180 180
Slight
420 360
Severe
180
Slight
LC = left circumflex
artery;
PTCA = percutaneous
FIGURE 1. An example of ST-segment altemansasrecorddfrompatient3on electrwardiiraphic lead V5 at 25 mm/s.
alternans (Figure 1). Pulsus alternans was not noted by either arterial or intracoronary blood pressure monitoring, whereas the perception of angina ranged from minimal to severe during the period of ST-segment alternans. All patients described in this report had normal electrolytes and QT intervals. All patients were pretreated with both nitrates and calcium antagonists (nifedipine or diltiazem). The procedures were performed with a variety of contrast agents (iohexal, and diatrizoate and ioxaglate meglumine sodiums). Patient 4 had previous PTCA at the same site without ST-segment alternans, but balloon inflation times then were 7The present report and other studies in humans2>4 have shown no hemodynamic alterations during ST-segment alternans. These findings need further confirmation with either echocardiographic or catheter tip transducer techniques.
ST-segment alternans in our patients occurred only during relatively prolongedballoon dilatations. This suggests that a threshold of ischemia may be required to induce ST-segmentalternans.Presenceof demonstrable collaterals in severalpatients, and their ability to tolerate prolonged balloon inflations, implies that ST-segment alternansmay be lessischemicin responsethan progressive ST-segment elevation. ST-segment alternans may be part of the continuum of ST-segment responsesto transmural myocardial ischemia. This hypothesisis supported by the observationof ST-segmentalternans progressingto uniform ST-segment elevation. This study suggeststhat ST-segment alternans is a relatively rare phenomenon during PTCA and occurs without significant sequelae.Extensive use of calcium antagonists in these patients may be suppressingthe manifestation of ST-segmentalternans.7Alternans may have been too localized to distinguish with standard electrocardiography. Monitoring 12-lead electrocardiograms, orthagonal leads, intracoronary electrodes or monophasicaction potentials may have yielded a greater prevalenceof this phenomenon. 1. H&r&n HK. Liebow IM. Electrical alternation in experimental coronary artery occlusion. Am J Physior 1950;160:366-374. 2. Joyal M, Feldman R, Pepine CJ. ST-segment alternans during percutaneous transluminal coronary angioplasty. Am J Cardiol 1984;54:915-916. 3. Salerno JA, Previtali M, Panciroli C, Klersy C, Chimienti M, Bonora MR, Marangoni E, Falcone C, Guasti L, Campana C, Rondanelli R. Ventricular arrhythmias during acute myocardial ischaemia in man. The role and significance of R-ST-T alternans and the prevention of ischaemic sudden death by medical treatment. Eur Heart J 1986;7A:63-75. 4. Sutton PMI, Taggart P, Lab M, Runnalls ME, O’Brien W, Treasure T. Alternans of epicardial repolarization as a localized phenomenon in man. Eur Heart J 1991;12:70-78. 5. Kleinfeld M, Stein E, Kossmann CE. Electrical alternans with emphasis on recent observations made by means of a single-cell electrical recording. Am Heart J 1963;65:495-500, 6. Roselle HA, Crampton RS, Case RB. Alternans of the deprased ST-segment during coronary insufficiency. Am J Cardiol 1966;18:200-207. 7. Hashimoto H, Suzuki K, Miyake S, Nakashima M. Effects of calcium antagonists on the electrical alternans of the ST segment and on associated mechanical alternans during acute coronary occlusion in dogs. Circulation 1983;68:667-672.
BRIEF REPORTS 1535
