Anger-induced T-wave alternans predicts future ventricular arrhythmias in patients with implantable cardioverter-defibrillators

J Am Coll Cardiol. 2009 Mar 3;53(9):774-8. doi: 10.1016/j.jacc.2008.10.053.


Objectives: This study sought to determine whether T-wave alternans (TWA) induced by anger in a laboratory setting predicts future ventricular arrhythmias in patients with implantable cardioverter-defibrillators (ICDs).

Background: Anger can precipitate spontaneous ventricular tachycardia/ventricular fibrillation and induce TWA. Whether anger-induced TWA predicts future arrhythmias is unknown.

Methods: Sixty-two patients with ICDs underwent ambulatory electrocardiography during a mental stress protocol, 3 months after the ICD was implanted. T-wave alternans was analyzed using time-domain methods. After a > or =1 year follow-up, ICD stored data was reviewed to determine incidence of ICD-terminated ventricular tachycardia/ventricular fibrillation.

Results: Patients with ICD-terminated arrhythmias during follow-up (n = 10) had higher TWA induced by anger, 13.2 microV (interquartile range [IQR] 9.3 to 16 microV), compared with those patients without future ventricular arrhythmias, 9.3 microV (IQR 7.5 to 11.5 microV, p < 0.01). Patients in the highest quartile of anger-induced TWA (>11.9 microV, n = 15) were more likely to experience arrhythmias by 1 year than those in the lower quartiles (33% vs. 4%) and during extended follow-up (40% vs. 9%, p < 0.01 for both). In multivariable regression controlling for ejection fraction, prior clinical arrhythmia, and wide QRS, anger-induced TWA remained a significant predictor of arrhythmia, with likelihood in the top quartile 10.8 times that of other patients (95% confidence interval: 1.6 to 113, p < 0.05).

Conclusions: Anger-induced TWA predicts future ventricular arrhythmias in patients with ICDs, suggesting that emotion-induced repolarization instability may be 1 mechanism linking stress and sudden death. Whether there is a clinical role for anger-induced TWA testing requires further study.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anger*
  • Cardiomyopathy, Dilated / complications
  • Coronary Artery Disease / complications
  • Defibrillators, Implantable*
  • Female
  • Heart Rate
  • Humans
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Predictive Value of Tests
  • Risk Factors
  • Stress, Psychological / complications*
  • Tachycardia, Ventricular / epidemiology
  • Tachycardia, Ventricular / etiology
  • Tachycardia, Ventricular / psychology*
  • United States / epidemiology
  • Ventricular Fibrillation / epidemiology
  • Ventricular Fibrillation / etiology
  • Ventricular Fibrillation / psychology*