Prognostic value of myocardial electric instability markersin patients with ischemic heart disease

Authors: O.I. Gromova, E.V. Kuznetsova, Ch.V. Hotsanyan, E.Z. Golukhova

Company: A.N. Bakoulev Scientific Center for Cardiovascular Surgery; Rublevskoe shosse, 135, Moscow, 121552, Russian Federation

Type:  Stable ischemic heart disease


For citation: Gromova O.I., Kuznetsova E.V., Hotsanyan Ch.V. et al. Prognostic value of myocardial electric instability markers in patients with ischemic heart disease. Creative Cardiology. 2015; 3: 26-41 (in Russian)

Keywords: sudden cardiac death malignant arrhythmias micrivolt T-wave alternans signal-averaged ECG late ventricular potentials filtered QRS duration heart rate turbulence

Full text:  



Objective. To estimate prognostic value of noninvasive electrophysiological tests as predictors of malignant ventricular arrhythmias (MA) in patients with CAD in long-term follow-up.

Material and methods. We prospectively enrolled 97 patients with CAD at the mean age of 61±10 years. The mean left ventricular ejection fraction (LVEF) was 50±13%. We defined 2 groups of pts: preserved LVEF (>40%) (n=66), and reduced LVEF (≤40%) (n=31). We calculated following noninvasive electrophysiological markers as part of 24-hour Holter monitoring: microvolt T-wave alternans (MTWA), signal-averaged electrocardiography (SAECG), Q–T-interval duration and dynamics, heart rate turbulence (HRT) and variability (HRV). Most of pts (89%) were revascularized before enrolling for during follow-up.

Results. Life-threatening ventricular arrhythmias were observed in 11 (11%) patients during mean follow-up period of 25±11 months: 5 (8%) in pts with preserved LVEF, and 6 (18%) in pts with LVEF≤40%. Cardiac mortality was 8% in common group: 3 and 19% in each group of pts. According to univariate analysis predictors of MA were: filtered QRS (P<0,05); abnormal HRT (P=0,01) and turbulence slope (TS) (P<0,01). The last two parameters were also significantly associated with cardiac mortality (P=0,002 и P<0,0001, respectively). Abnormal TRS was independent predictor of MA according to multivariate Cox regression analysis (P<0,01). Late ventricular potentials (LVP) by SAECG were associated with MA in pts with preserved LVEF (P=0,043). Neither of analyzed ECG parameters had significant association with MA in pts with LVEF≤40%. Non-negative MTWA-test and turbulence onset (TО) predicted cardiac mortality in pts with reduced EF (P=0,018 and P=0,02, respectively).

Conclusion. Abnormal HRT is independent predictor of MA in CAD pts and had significant influence on cardiac mortality. Late ventricular potentials can be predictors of MA in pts with LVEF>40%. Non-negative MTWA-test and abnormal TO are associated with cardiac mortality in pts with LVEF≤40%.


  1. Bigger J.T., Jr. Identification of patients at high risk for sudden cardiac death. Am. J. Cardiol. 1984; 54 (9): 3D–8D.

  2. Бокерия Л.А., Ревишвили А.Ш. Внезапная сердечная смерть. М.: ГЭОТАР-Медиа; 2011.

  3. Epstein A.E., Di Marco J.P., Ellenbogen K.A., Estes N.A., Freedman R.A., Gettes L.S. et al. 2012 ACCF/AHA/HRS Focused Update incorporated into the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and Heart Rhythm Society. J. Am. Coll. Cardiol. 2013; 61 (3): e6–e75.

  4. Bardy G.H., Lee K.L., Mark D.B., Poole J.E., Packer D.L., Boineau R. et al. Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N. Engl. J. Med. 2005; 352: 225–37.

  5. Gandhi K., Aronow W.S., Desai H., Amin H., Lai H.M., Fishman W.H. et al. Incidence of appropriate cardioverter-defibrillator shocks and mortality in patients with implantable cardioverterdefibrillators with ischemic cardiomyopathy versus nonischemic cardiomyopathy at 33-month follow-up. Arch. Med. Sci. 2010; 6 (6): 900–3.

  6. Reynolds M.R., Cohen D.J., Kugelmass A.D., Brown P.P., Becker E.R., Culler S.D. et al. The Frequency and Incremental Cost of Major Complications Among Medicare Beneficiaries Receiving Implantable Cardioverter-Defibrillators. J. Am. Coll. Cardiol. 2006; 47: 2493–7.

  7. Неминущий Н.М. Имплантируемые кардиовертеры-дефибрилляторы в лечении жизнеугрожающих тахиаритмий и профилактике внезапной сердечной смерти: Афтореф: дис. … д-ра. мед. наук. М.; 2002.

  8. Громова О.И., Александрова С.А., Макаренко В.Н. Голухова Е.З. Современные предикторы жизнеугрожающих аритмий. Креативная кардиология. 2012; 2: 30–46.

  9. Голухова Е.З., Громова О.И., Мерзляков В.Ю., Шумков К.В., Бокерия Л.А. Турбулентность ритма сердца и мозговой натрийуретический пептид как предикторы жизнеугрожающих аритмий у больных с ишемической болезнью сердца. Креативная кардиология. 2013; 2: 62–77.

  10. Bloomfield D.M., Hohnloser S.H. Interpretation and classification of MTWA tests. J. Cardiovasc. Electrophysiol. 2002; 13: 502–12.

  11. Levy W.C., Lee K.L., Hellkamp A.S., Poole J.E., Mozaffarian D., Linker D.T. Maximizing Survival Benefit With Primary Prevention Implantable Cardioverter-Defibrillator Therapy in a Heart Failure Population. Circulation. 2009; 120: 835–42.

  12. Gold M.R., Ip J.H., Constantini O., Poole J.E., McNulty S., Mark D.B. et al. Role of microvolt T-wave alternans in assessment of arrhythmia vulnerability among patients with heart failure and systolic dysfunction: primary results from the T-wave alternans sudden cardiac death in heart failure trial substudy. Circulation. 2008; 118: 2022–28.

  13. Costantini O., Hohnloser S.H., Kirk M.M., Lerman B.B., Baker J.H., II, Sethuraman B. et al. The ABCD (Alternans Before Cardioverter Defibrillator) Trial: strategies using T-wave alternans to improve efficiency of sudden cardiac death prevention. J. Am. Coll. Cardiol. 2009; 53: 471–9.

  14. Zipes D.P., Camm A.J., Borggrefe M., Buxton A.E., Chaitman B., Fromer M. et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 114: e385–e484.

  15. Merchant F.M., Ikeda T., Pedretti R.F.E., Salerno-Uriarte J.A., Chow T., Chan P.S. et al. Clinical Utility of Microvolt T-wave Alternans Testing In Identifying Patients at High or Low Risk of Sudden Cardiac Death. Heart Rhythm. 2012; 9 (8): 1256–64.

  16. Goldberger J.J., Cain M.E., Hohnloser S.H., Kadish A.H., Knight B.P., Lauer M.S. et al. American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society Scientific Statement on Noninvasive Risk Stratification Techniques for Identifying Patients at Risk for Sudden Cardiac Death. J. Am. Coll. Cardiol. 2008; 52: 1179–99.

  17. Rubart M., Zipes D.P. Mechanisms of sudden cardiac death. J. Clin. Invest. 2005; 115: 2305–15.

  18. Шляхто Е.В., Бернгардт Э.Р., Пармон Е.В., Цветникова А.А. Турбулентность сердечного ритма в оценке риска внезапной сердечной смерти. Вестник аритмологии. 2004; 38: 49–55.

  19. Bauer A., Barthel P., Müller A., Ulm K., Huikuri H., Malik M. et al. Risk prediction by heart rate turbulence and deceleration capacity in postinfarction patients with preserved left ventricular function retrospective analysis of 4 independent trials. J. Electrocardiol. 2009; 42 (6): 597–601.

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery