Electrical Alternans

- Prof.M.K.Sudhakars unit

29 yr , male pt No comorbidities C/o cough with expectoration 1 mth Dyspnea 15 days progressed from grade 2 to 4 No other associated complaint

O/E : Conscious, oriented, afebrile, tachypneic PR 116/mt, BP 110/70 mmhg CVS s1 , s2 +, no murmurs RS NVBS +, B/L basal crepts Abd soft , BS + CNS - NFND

Labs
Hb/Plat - N Tc 23170 (p-84.1) RBS/RFT/Sr.Elect N LFT T.B - 1.53 / D.B - 0.65 SGOT - 27 / SGPT 96 ESR - 62 Urine R/e N CxR(bedside) B/L LZ congestion, cardiomegaly,B/L CP angle blunting BNP 45.8 pg/ml ECG NSR , no ST-T changes Outside echo normal LV function with no RWMA

 Pt was managed in ICU as CAP with -O2 - Antibiotics - other supportives Blood, sputum & urine C/s no growth

On day 2

Developed hypotention ECG in ICU monitor showed

 Cardiology opinion was sought from Prof.S.Thanikachalam Suspected to have pericardial effusion Urgent Echo was done & found to have massive pericardial effusion with swinging heart Around 750 ml pericardial fluid was drained

Pericardial fluid analysis

Sugar 10 mgm/dl Protein 5.3 gm/dl WBC 32cells/cumm(P-80%,L-20%) RBC 7400 cells/cumm(norm-80%,cren-20%) ADA 64 IU/L PCR TB negative c/s no growth AFB not seen Cytology mesothelial cells

 Pt was started on ATT Follow up echo showed very minimal pericardial effusion

Discussion
Electrical alternans is a broad term that describes alternate beat variation in direction, amplitude & duration of any component of ECG 3 types : Repolarization alternans (ST,T) Conduction alternans (P,PR,QRS) Alternans due to cardiac motion

Repolarization alternans
ST segment alternans : Alternating ST elevation - usually in presence of MI Causes Acute MI Vasospastic angina pectoris During PTCA Subarachnoid haemorrhage

T wave alternans : Associated with rapid changes in HR or prolonged QT interval Predictor of ventricular tachyarrythmias Causes : Congenital long QT syndrome Dyselectrolemia (hypocalcemia,hypokalemia,hypomagnesemia) Hypertrophic cardiomyopathy CCF TPI

Conduction alternans
Alteration in impulse propagation along any of anatomic structures involved in conduction of electrical impulse Alteration of P/QRS complex/PR interval/RR interval Causes: Myocardial ischaemia AF WPW syndrome RHD LV dysfunction

Electrical alternans associated with cardiac motion

Alteration in heart position in relation to electrodes Total electrical alternans Causes: Pericardial tamponade Hypertrophic cardiomyopathy Total electrical alternans 5 - 10 % of cardiac tamponade cases

Thank you