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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
- 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.
Pulsus alternans has long been recognized as a manifestation of severe congestive heart failure [1, 2]. 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 [3, 4]. This results in part from the marked attenuation of parasympathetic tone in congestive heart failure, which governs such rapid fluctuations in heart period [3-5]. 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.
Methods
Case Report
A 55-year-old white woman with idiopathic dilated cardiomyopathy had an angiographically measured ejection fraction of 19% and had New York Heart Association functional class III symptomatic congestive heart failure. She was referred to Ohio State University Hospital for further management of congestive heart failure. As part of her evaluation, she had hemodynamic assessment of her response to vasodilator administration using a protocol that was reviewed and approved by the Human Use Review Board of The Ohio State University; the patient provided informed consent. The patient had received nitroglycerin ointment, 1 inch every 8 hours, and had received furosemide for management of heart failure symptoms before admission. In accordance with the protocol, nitrates and diuretic agents were withheld on the evening before the hemodynamic evaluation.
Hemodynamic Evaluation
A 6-fr Millar catheter (Millar Instruments, Houston, Texas) with a micromanometer pressure transducer was …
