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Unusual sinus arrhythmia or heart rate alternans
270
Letters to the Editor
It is, thus, reasonable to consider that sinus arrhythmia under focus may represent a form of concealed sinus bigeminy, which is apparently and (almost) exclusively detectable by power spectral analysis of RR interval sequence. Further studies are necessary to establish its prevalence in general population, cardiac disorders frequently associated, its precise electrophysiological mechanism and prognostic significant. References [1] Gratadour P, et al. Unusual sinus arrhythmia. Int J Cardiol 2008;127: e138–41. [2] Hering DE. Das Wesen des Herzalterns. Munchen Med Wochenshr 1908;4:1417–21.
[3] Lewis T. Notes upon alternation of the heart. Q J Méd 1910;4:141–4. [4] Benchimol-Barbosa PR, Barbosa-Filho J, Bomfim AS, et al. T-wave electrical alternans: electrophysiological basis and evidence-based clinical application. Rev SOCERJ 2004;17:218–33 (in Portuguese). [5] Gmachl E. Sinus bigeminy. Wien Klin Wochenschr 1954;66(27): 480–2. [6] Binkley PF, Eaton GM, Nunciata E, et al. Heart rate alternans. Ann Intern Med 1995;122:115–7. [7] Barbosa-Filho J, Barbosa PR, Cordovil I. Nonrespiratory sinus arrhythmia. Arq Bras Cardiol 2002;78:409–11. [8] Öztürk M, Demirog C. Alternating sinus rhythm and intermittent sinoatrial block induced by propranolol. Eur Heart J 1984;5:890–5. [9] Satullo G, Cavallaro L. Intermittent sinus bigeminy as an expression of sinus parasystole: a case report. J Electrocardiol Oct 1999;32(4): 355–8.
0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.11.052
Unusual sinus arrhythmia or heart rate alternans Andrei Cividjian, Pierre Gratadour, Luc Quintin ⁎ Physiology, University of Lyon1-CNRS UMR 5123, Lyon, France Received 30 January 2008; accepted 10 May 2008 Available online 24 June 2008
Keywords: Sinus arrhythmia; Respiratory sinus arrhythmia
Sir, Dr Benchimol-Barbosa is thanked for his reply [1] to our report on “unusual sinus arrhythmia” [4] (“heart rate [HR] alternans” [2]) and updating our references. To define the phenomenon, strict criteria are proposed [1]: “1) the continuous and visually undetectable beat-to-beat alternation of RR interval in a long-short sequence 2) the average frequency content concentration above 0.5 Hz and peaking exactly the frequency corresponding half of the HR of the analysed sequence in sinus rhythm 3) the nearly invariant P wave morphology 4) lack of either sympathetic [SNS] or parasympathetic [PNS] autonomic RR interval modulation during analysed period 5) no relation to respiratory activity 6) peripheral pulse wave amplitude alternation”. Previous observations [2,3] are identical to ours. Benchimol-Barbosa shows two distinct peaks, in their letter [1] and previous observation (circa 0.5–0.65 Hz: Fig. 3 vs. circa ⁎ Corresponding author. E-mail address: [email protected] (L. Quintin).
0.27 Hz: Fig. 2 in [2]). These 2 peaks are not observed in the same patient but contrasted in two different patients and a control subject. Binkley [3] shows an alternation between a 600–620 ms “fixed” RR interval and a 580–660 ms RR interval. Thus two distinct peaks (below 0.1 vs. 0.8 Hz) appear on his power spectral density graph of HR (Fig. 1 in [3]). Some differences exist: 1) our relatively healthy hypertensive subjects [4] are opposed to patients presenting with congestive heart failure [3] or angina [2] 2) the heart rate alternans is documented for a period of time lasting hours to at least half a day in the same patients [4] 3) since our first recording, we documented this phenomenon several times: does this imply that this heart rate alternans is underreported? Following Dr Barbosa, we observed 2 different peaks respectively related and unrelated to ventilation in our previous figure (Fig. 1D) [4] in the same patients: heart rate alternans and normal sinus rhythm were alternating within a very short period of time in patient no. 1 [4]. By contrast the recording displayed in present Fig. 1 shows heart rate alternans occurring during the early recovery period, then disappearing to normal sinus
Letters to the Editor
271
Fig. 1. A Recordings of beat-by-beat heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), area under the QRS-wave curve (QRS) and ventilatory rate (spontaneous ventilation; Ventilation) derived from the QRS signal few hours after surgery (left) and one day after surgery (right) in patient no. 2 described in our previous letter [4]. B Spectral power (Fast Fourier Transform) of each recording of HR, SBP, DBP and QRS signals showed in A. Original signals interpolated using cubic splines then re-sampled (2 Hz). Ventilatory fluctuations (11 cycles/min = 0.18 Hz) are visible on HR (right), SBP (right and slightly in left), DBP (right) and QRS (right and left) time series. These ventilatory fluctuations are visible on all the spectra at 0.18 Hz (arrow). Unusual arrhythmia is visible on the HR and DBP time series during the first recording (left). This unusual arrhythmia is visible on the HR and DBP spectra at higher frequencies corresponding to a period of 2 heart beats (HR = 70 bpm = 1.17 Hz) i.e. at 0.58 Hz.
rhythm the next day in patient no. 2 reported in our previous letter [4]. Beat-to-beat and breath-to-breath recording of the circulatory and ventilatory parameters is needed in the same patient to directly delineate the changes in phase between HR and ventilation (non-respiratory arrhythmia): Is the highest frequency observed in HR actually twice as fast as the frequency usually related to ventilation? What are the
relationships between systolic pressure (SBP) and HR? diastolic pressure (DBP) and HR? The highest SBP accompanies the shortest RR intervals (Fig. 2 in [3]). The lowest SBP accompanies the longest RR interval (pulsus alternans) [3]. Does this imply longer diastolic run off from the Windkessel during longest RR interval? How can such a nice arrangement to level off pressure lability be compatible with presumably low sensitivity of the cardiac
272
Letters to the Editor
baroreflex in congestive heart failure? We observed similar variations: see HR and DBP traces in Binkley's report [3] in Fig. 1 of our previous observation [4] and present Fig. 1. Finally, such a heart rate alternans, when captured in the same human, would be useful to study beat-to-beat HR–BP relationship in addition to the pacing of the heart [5].
References [1] Benchimol-Barbosa PR, Barbosa-Filho J. “Nonrespiratory sinus arrhythmia” or “Heart rate alternans”: Comments on the article by Gratadour et al: “Unusual sinus arrhythmia”. Int J Cardiol 2008;133: 268–70. [2] Barbosa Filho J, Barbosa PRB, Cordovil I. Non respiratory sinus arrhythmia. Arq Bras Cardiol 2002;78:409–11. [3] Binkley PF, Eaton GM, Nunziata E, Khot U, Cody RJ. Heart rate alternans. Ann Int Med 1995;122:115–7. [4] Gratadour P, Cividjian A, Sagnard P, Parlow J, Viale JP, Quintin L. Unusual sinus arrhythmia. Int J Cardiol 2008;127:e138–41.
0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.05.003
Diverse clinical spectrum of stress-induced cardiomyopathy Yian-Ping Lee a,⁎, Kian-Keong Poh a , Chi-Hang Lee a,b , Huay-Cheem Tan a,b , Abdul Razak a , Boon-Lock Chia a,b , Adrian F. Low a,b b
a Cardiac Department, National University Hospital, Singapore Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Received 18 August 2007; accepted 12 November 2007 Available online 10 January 2008
Abstract Stress-induced cardiomyopathy or Takotsubo cardiomyopathy is an uncommon disorder characterized by apical ballooning. The etiology and pathophysiology of this syndrome has not been fully evaluated. This case series examined the clinical characteristics and outcomes of 10 patients with confirmed stress-induced cardiomyopathy. We identified 10 cases of stress-induced cardiomyopathy. All exhibit characteristic apical ballooning and basal hyperkinesia except one with an “inverted Takotsubo” pattern. Coronary angiography excluded coronary artery stenoses as a cause of cardiomyopathy. Patient characteristics, cardiac function, follow-up echocardiography and outcomes were determined. 60% of cases were female and 70% of cases had ST-segment elevations. Identified precipitants included severe emotional stress, subarachnoid haemorrhage and sepsis. None of the cases had angiographically significant coronary stenosis. One patient had an “inverted Takotsubo” pattern with mid-ventricular ballooning. Stress-induced cardiomyopathy is a clinical spectrum which can present with a classical “Takotsubo” or “inverted Takotsubo” pattern. Presentation is varied but characterized by recovery to normal cardiac systolic function. Study of this syndrome may enhance further understanding of the “brain–heart” relationship. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Stress-induced cardiomyopathy; Takotsubo cardiomyopathy; Inverted Takotsubo
1. Introduction Stress-induced cardiomyopathy or transient left ventricular apical ballooning, also called Takotsubo cardiomyopathy, ⁎ Corresponding author. Cardiac Department, National University Hospital, Singapore, 5 Lower Kent Ridge Road, Level 3, Main Building, 119074 Singapore. Tel.: +65 6772 5260; fax: +65 6777 1684. E-mail address: [email protected] (Y.-P. Lee).
was first described in Japan [1]. It is characterized by transient hypokinesia of the apical portion of the left ventricle with compensatory hyperkinesia of the basal walls, resulting in apical ballooning which gives the heart the appearance of a Japanese octopus trap or “Takotsubo”. This syndrome is triggered by severe emotional or physical stressors and mimics an acute coronary syndrome. Electrocardiograms often reveal ST-segment elevations followed by T wave inversions in the precordial leads. Cardiac enzymes
Letters to the Editor
It is, thus, reasonable to consider that sinus arrhythmia under focus may represent a form of concealed sinus bigeminy, which is apparently and (almost) exclusively detectable by power spectral analysis of RR interval sequence. Further studies are necessary to establish its prevalence in general population, cardiac disorders frequently associated, its precise electrophysiological mechanism and prognostic significant. References [1] Gratadour P, et al. Unusual sinus arrhythmia. Int J Cardiol 2008;127: e138–41. [2] Hering DE. Das Wesen des Herzalterns. Munchen Med Wochenshr 1908;4:1417–21.
[3] Lewis T. Notes upon alternation of the heart. Q J Méd 1910;4:141–4. [4] Benchimol-Barbosa PR, Barbosa-Filho J, Bomfim AS, et al. T-wave electrical alternans: electrophysiological basis and evidence-based clinical application. Rev SOCERJ 2004;17:218–33 (in Portuguese). [5] Gmachl E. Sinus bigeminy. Wien Klin Wochenschr 1954;66(27): 480–2. [6] Binkley PF, Eaton GM, Nunciata E, et al. Heart rate alternans. Ann Intern Med 1995;122:115–7. [7] Barbosa-Filho J, Barbosa PR, Cordovil I. Nonrespiratory sinus arrhythmia. Arq Bras Cardiol 2002;78:409–11. [8] Öztürk M, Demirog C. Alternating sinus rhythm and intermittent sinoatrial block induced by propranolol. Eur Heart J 1984;5:890–5. [9] Satullo G, Cavallaro L. Intermittent sinus bigeminy as an expression of sinus parasystole: a case report. J Electrocardiol Oct 1999;32(4): 355–8.
0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.11.052
Unusual sinus arrhythmia or heart rate alternans Andrei Cividjian, Pierre Gratadour, Luc Quintin ⁎ Physiology, University of Lyon1-CNRS UMR 5123, Lyon, France Received 30 January 2008; accepted 10 May 2008 Available online 24 June 2008
Keywords: Sinus arrhythmia; Respiratory sinus arrhythmia
Sir, Dr Benchimol-Barbosa is thanked for his reply [1] to our report on “unusual sinus arrhythmia” [4] (“heart rate [HR] alternans” [2]) and updating our references. To define the phenomenon, strict criteria are proposed [1]: “1) the continuous and visually undetectable beat-to-beat alternation of RR interval in a long-short sequence 2) the average frequency content concentration above 0.5 Hz and peaking exactly the frequency corresponding half of the HR of the analysed sequence in sinus rhythm 3) the nearly invariant P wave morphology 4) lack of either sympathetic [SNS] or parasympathetic [PNS] autonomic RR interval modulation during analysed period 5) no relation to respiratory activity 6) peripheral pulse wave amplitude alternation”. Previous observations [2,3] are identical to ours. Benchimol-Barbosa shows two distinct peaks, in their letter [1] and previous observation (circa 0.5–0.65 Hz: Fig. 3 vs. circa ⁎ Corresponding author. E-mail address: [email protected] (L. Quintin).
0.27 Hz: Fig. 2 in [2]). These 2 peaks are not observed in the same patient but contrasted in two different patients and a control subject. Binkley [3] shows an alternation between a 600–620 ms “fixed” RR interval and a 580–660 ms RR interval. Thus two distinct peaks (below 0.1 vs. 0.8 Hz) appear on his power spectral density graph of HR (Fig. 1 in [3]). Some differences exist: 1) our relatively healthy hypertensive subjects [4] are opposed to patients presenting with congestive heart failure [3] or angina [2] 2) the heart rate alternans is documented for a period of time lasting hours to at least half a day in the same patients [4] 3) since our first recording, we documented this phenomenon several times: does this imply that this heart rate alternans is underreported? Following Dr Barbosa, we observed 2 different peaks respectively related and unrelated to ventilation in our previous figure (Fig. 1D) [4] in the same patients: heart rate alternans and normal sinus rhythm were alternating within a very short period of time in patient no. 1 [4]. By contrast the recording displayed in present Fig. 1 shows heart rate alternans occurring during the early recovery period, then disappearing to normal sinus
Letters to the Editor
271
Fig. 1. A Recordings of beat-by-beat heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), area under the QRS-wave curve (QRS) and ventilatory rate (spontaneous ventilation; Ventilation) derived from the QRS signal few hours after surgery (left) and one day after surgery (right) in patient no. 2 described in our previous letter [4]. B Spectral power (Fast Fourier Transform) of each recording of HR, SBP, DBP and QRS signals showed in A. Original signals interpolated using cubic splines then re-sampled (2 Hz). Ventilatory fluctuations (11 cycles/min = 0.18 Hz) are visible on HR (right), SBP (right and slightly in left), DBP (right) and QRS (right and left) time series. These ventilatory fluctuations are visible on all the spectra at 0.18 Hz (arrow). Unusual arrhythmia is visible on the HR and DBP time series during the first recording (left). This unusual arrhythmia is visible on the HR and DBP spectra at higher frequencies corresponding to a period of 2 heart beats (HR = 70 bpm = 1.17 Hz) i.e. at 0.58 Hz.
rhythm the next day in patient no. 2 reported in our previous letter [4]. Beat-to-beat and breath-to-breath recording of the circulatory and ventilatory parameters is needed in the same patient to directly delineate the changes in phase between HR and ventilation (non-respiratory arrhythmia): Is the highest frequency observed in HR actually twice as fast as the frequency usually related to ventilation? What are the
relationships between systolic pressure (SBP) and HR? diastolic pressure (DBP) and HR? The highest SBP accompanies the shortest RR intervals (Fig. 2 in [3]). The lowest SBP accompanies the longest RR interval (pulsus alternans) [3]. Does this imply longer diastolic run off from the Windkessel during longest RR interval? How can such a nice arrangement to level off pressure lability be compatible with presumably low sensitivity of the cardiac
272
Letters to the Editor
baroreflex in congestive heart failure? We observed similar variations: see HR and DBP traces in Binkley's report [3] in Fig. 1 of our previous observation [4] and present Fig. 1. Finally, such a heart rate alternans, when captured in the same human, would be useful to study beat-to-beat HR–BP relationship in addition to the pacing of the heart [5].
References [1] Benchimol-Barbosa PR, Barbosa-Filho J. “Nonrespiratory sinus arrhythmia” or “Heart rate alternans”: Comments on the article by Gratadour et al: “Unusual sinus arrhythmia”. Int J Cardiol 2008;133: 268–70. [2] Barbosa Filho J, Barbosa PRB, Cordovil I. Non respiratory sinus arrhythmia. Arq Bras Cardiol 2002;78:409–11. [3] Binkley PF, Eaton GM, Nunziata E, Khot U, Cody RJ. Heart rate alternans. Ann Int Med 1995;122:115–7. [4] Gratadour P, Cividjian A, Sagnard P, Parlow J, Viale JP, Quintin L. Unusual sinus arrhythmia. Int J Cardiol 2008;127:e138–41.
0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.05.003
Diverse clinical spectrum of stress-induced cardiomyopathy Yian-Ping Lee a,⁎, Kian-Keong Poh a , Chi-Hang Lee a,b , Huay-Cheem Tan a,b , Abdul Razak a , Boon-Lock Chia a,b , Adrian F. Low a,b b
a Cardiac Department, National University Hospital, Singapore Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Received 18 August 2007; accepted 12 November 2007 Available online 10 January 2008
Abstract Stress-induced cardiomyopathy or Takotsubo cardiomyopathy is an uncommon disorder characterized by apical ballooning. The etiology and pathophysiology of this syndrome has not been fully evaluated. This case series examined the clinical characteristics and outcomes of 10 patients with confirmed stress-induced cardiomyopathy. We identified 10 cases of stress-induced cardiomyopathy. All exhibit characteristic apical ballooning and basal hyperkinesia except one with an “inverted Takotsubo” pattern. Coronary angiography excluded coronary artery stenoses as a cause of cardiomyopathy. Patient characteristics, cardiac function, follow-up echocardiography and outcomes were determined. 60% of cases were female and 70% of cases had ST-segment elevations. Identified precipitants included severe emotional stress, subarachnoid haemorrhage and sepsis. None of the cases had angiographically significant coronary stenosis. One patient had an “inverted Takotsubo” pattern with mid-ventricular ballooning. Stress-induced cardiomyopathy is a clinical spectrum which can present with a classical “Takotsubo” or “inverted Takotsubo” pattern. Presentation is varied but characterized by recovery to normal cardiac systolic function. Study of this syndrome may enhance further understanding of the “brain–heart” relationship. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Stress-induced cardiomyopathy; Takotsubo cardiomyopathy; Inverted Takotsubo
1. Introduction Stress-induced cardiomyopathy or transient left ventricular apical ballooning, also called Takotsubo cardiomyopathy, ⁎ Corresponding author. Cardiac Department, National University Hospital, Singapore, 5 Lower Kent Ridge Road, Level 3, Main Building, 119074 Singapore. Tel.: +65 6772 5260; fax: +65 6777 1684. E-mail address: [email protected] (Y.-P. Lee).
was first described in Japan [1]. It is characterized by transient hypokinesia of the apical portion of the left ventricle with compensatory hyperkinesia of the basal walls, resulting in apical ballooning which gives the heart the appearance of a Japanese octopus trap or “Takotsubo”. This syndrome is triggered by severe emotional or physical stressors and mimics an acute coronary syndrome. Electrocardiograms often reveal ST-segment elevations followed by T wave inversions in the precordial leads. Cardiac enzymes