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Randomized Controlled Trial
. 2018 Mar;23(2):e12503.
doi: 10.1111/anec.12503. Epub 2017 Sep 26.

Marked exercise-induced T-wave heterogeneity in symptomatic diabetic patients with nonflow-limiting coronary artery stenosis

Fernando G Stocco  1   2 , Ederson Evaristo  1   2 , Nishant R Shah  3   4   5 , Michael K Cheezum  3   4 , Jon Hainer  3 , Courtney Foster  3 , Bruce D Nearing  2   4 , Ernest Gervino  2   4 , Richard L Verrier  2   4
Affiliations
Randomized Controlled Trial

Marked exercise-induced T-wave heterogeneity in symptomatic diabetic patients with nonflow-limiting coronary artery stenosis

Fernando G Stocco et al. Ann Noninvasive Electrocardiol. 2018 Mar.

Abstract

Background: T-wave heterogeneity (TWH) independently predicted cardiovascular mortality in Health Survey 2000 based on 12-lead ECGs recorded at rest. We investigated whether TWH is elevated during exercise tolerance testing (ETT) in symptomatic diabetic patients with nonflow-limiting coronary artery stenosis compared to control subjects without diabetes.

Methods: Cases were all patients (n = 20) with analyzable ECG recordings during both rest and ETT who were enrolled in the Effects of Ranolazine on Coronary Flow Reserve (CFR) in Symptomatic Patients with Diabetes and Suspected or Known Coronary Artery Disease (RAND-CFR) study (NCT01754259); median CFR was 1.44; 80% of cases had CFR <2. Control subjects (n = 9) were nondiabetic patients who had functional flow reserve (FFR) >0.8, a range not associated with inducible ischemia. TWH was analyzed from precordial leads V4 , V5 , and V6 by second central moment analysis, which assesses the interlead splay of T-waves about a mean waveform.

Results: During exercise to similar rate-pressure products (p = .31), RAND-CFR patients exhibited a 49% increase in TWH during exercise (rest: 49 ± 5 μV; exercise: 73 ± 8 μV, p = .003). By comparison, in control subjects, TWH was not significantly altered (rest: 52 ± 11 μV; ETT: 38 ± 5 μV, p = .19). ETT-induced ST-segment depression >1 mm (p = .11) and Tpeak -Tend (p = .18) and QTc intervals (p = .80) failed to differentiate cases from controls.

Conclusions: TWH is capable of detecting latent repolarization abnormalities, which are present during ETT in diabetic patients with nonflow-limiting stenosis but not in control subjects. The technique developed in this study permits TWH analysis from archived ECGs and thereby enables mining of extensive databases for retrospective studies and hypothesis testing.

Keywords: coronary artery disease; coronary flow reserve; diabetes; functional flow reserve; heterogeneity.

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Figures

Figure 1
Figure 1
Procedure for T‐wave heterogeneity (TWH) calculation. See Methods section for details
Figure 2
Figure 2
Digitized ECG tracings illustrate T‐wave heterogeneity (TWH) as interlead splay in repolarization morphology during rest and exercise in a representative control subject (upper panels) and a representative case (lower panels)
Figure 3
Figure 3
Absence of change in T‐wave heterogeneity (TWH) from rest to exercise in control subjects (open bars, n = 9, p = .19) compared to the significant, 49% increase in TWH in cases (filled bars, n = 20, p = .003)
Figure 4
Figure 4
Change in T‐wave heterogeneity (TWH) from rest to exercise. Left panel: Data from nine control subjects. Right panel: Data from 20 cases. Dashed lines indicate group means
Figure 5
Figure 5
Box plot comparison by quartiles of range of T‐wave heterogeneity (TWH) levels in cases (n = 20, left) and in control subjects (n = 9, right) during exercise
See this image and copyright information in PMC

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