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Heart Rate Alternans

Philip F. Binkley, MD; Gregory M. Eaton, MD; Enrico Nunziata, MSBME; Umesh Khot, BS; and Robert J. Cody, MD
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From The Ohio State University Medical Center, Columbus, Ohio. Requests for Reprints: Philip F. Binkley, MD, Division of Cardiology, The Ohio State University Medical Center, 6th Floor Means Hall, 1654 Upham Drive, Columbus, OH 43210-1228. Acknowledgments: The authors thank Trichia Greer for her assistance in the preparation of this manuscript.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1995;122(2):115-117. doi:10.7326/0003-4819-122-2-199501150-00007
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Pulsus alternans has long been recognized as a manifestation of severe congestive heart failure [12]. In contrast to the beat-to-beat oscillation in blood pressure that occurs with pulsus alternans, rapid beat-to-beat variations in heart rate are characteristically absent in the setting of ventricular failure [34]. This results in part from the marked attenuation of parasympathetic tone in congestive heart failure, which governs such rapid fluctuations in heart period [35]. Further, because of the reduction in baroreflex sensitivity in patients with congestive heart failure, it has been thought unlikely that heart rate would vary in an instantaneous fashion in response to the rapid changes in systolic pressure that occur with pulsus alternans. We describe an unexpected beat-to-beat variation in heart rate, or “heart rate alternans,” in a patient with congestive heart failure; this heart rate alternans is a previously unrecognized manifestation of pulsus alternans.

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Figure 1.
Power-density spectrum of heart rate variability in a patient with congestive heart failure.Figure 222

A. Heart rate variability in the absence of pulsus alternans. The spectrum is characteristic of patients who have congestive heart failure with an absence of heart rate variability at frequencies greater than 0.1 Hz. The high-frequency peak in heart rate variability noted during pulsus alternans (panel B) is absent. B. Heart rate variability during a period of pulsus alternans. In contrast to the usual spectrum in patients with congestive heart failure, a prominent peak occurred in high-frequency heart rate variability (compare with panel A). C. Systolic blood pressure during pulsus alternans. A high-frequency peak in blood pressure variability coincides with the peak in heart rate variability shown in panel B. This high-frequency peak in blood pressure variability corresponds to the two-beat cycle of alternating high- and low-amplitude systolic pressure waveforms that define pulsus alternans (see ). BPM = beats/min ; CHF = congestive heart failure.

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Figure 2.
Electrocardiogram (top) and central aortic pressure recording (bottom) obtained immediately before and during the onset of pulsus alternans.arrow

The recordings show that heart rate alternans appears to follow, rather than precede, pulsus alternans. A relatively stable electrocardiographic (ECG) cycle length is maintained before the onset of pulsus alternans (cycle length indicated above crossbars on the ECG recording). Pulsus alternans is initiated with a high-amplitude aortic pressure wave ( ) with subsequent alternating variations in ECG cycle length (heart rate alternans) that are of a magnitude greater than that of previous beat-to-beat variations in cycle duration.

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