Clinical and hemodynamic characteristics of patients with inducible pulsus alternans

Pulsus alternans can be found in some patients with abnormal left ventricular function and also can develop after spontaneous premature beats. The purposes of this study were to: (1) determine the inducibility of pulsus alternans in a series of patients referred for routine cardiac catheterization and (2) define the clinical and hemodynamic characteristics of those who develop pulsus alternans. In 104 patients referred for right and left heart catheterization, atrial premature beats and rapid atrial pacing were used to try to provoke pulsus alternans. The 29 patients who developed pulsus alternans in response to these maneuvers were older (63 ± 6 vs 59 ± 10 years, p < 0.01) and had a greater incidence of valvular heart disease (45% vs 23%, p < 0.01) and congestive heart failure (38% vs 17%, p < 0.05). Aortic stenosis was the most prevalent valve lesion found. Those who developed pulsus alternans in response to pacing were further characterized by higher left ventricular systolic (143 ± 42 vs 121 ± 23 mm Hg, p < 0.02) and end-diastolic pressures (17 ± 9 vs 13 ± 6 mm Hg, p < 0.05), higher pulmonary artery systolic pressure (35 ± 14 vs 29 ± 11 mm Hg, p < 0.04), and lower left ventricular ejection fractions (0.42 ± 0.13 vs 0.53 ± 0.14, p < 0.001). Eight patients (28%) with inducibile pulsus alternans had a normal left ventricular ejection fraction (>0.50) and left ventricular end-diastolic pressure (<13 mm Hg). This study demonstrates that pulsus alternans can be induced in a substantial number of patients referred for routine cardiac catheterization and can occur in some patients who have normal left ventricular ejection fractions and end-diastolic pressures. The possibility that inducible pulsus alternans imparts prognostic information in selected patients may warrant further study.