Temporal Changes in Beat-to-Beat Variability of Repolarization Predict Imminent Nonsustained Ventricular Tachycardia in Patients With Ischemic and Nonischemic Dilated Cardiomyopathy

Background An increase in beat-to-beat variability of repolarization (BVR) predicts arrhythmia onset in experimental models, but its clinical translation is not well established. We investigated the temporal changes in BVR before nonsustained ventricular tachycardia (nsVT) in patients with implantable cardioverter defibrillator (ICD). Methods and Results Patients with nsVT on 24-hour Holter before ICD implantation for ischemic cardiomyopathy (ischemic cardiomyopathy+nsVT, n=43) or dilated cardiomyopathy (dilated cardiomyopathy+nsVT, n=37), matched ICD candidates without nsVT (ischemic cardiomyopathy-nsVT, n=29 and dilated cardiomyopathy-nsVT, n=26), and patients without ICD without structural heart disease (n=50) were studied. Digital Holter recordings from these patients were analyzed using a modified fiducial segment averaging technique to detect the QT interval. The nsVT episodes were semi-automatically identified and QT-BVR was assessed 1-, 5-, and 30-minutes before nsVT, and at rest (at 3:00 am). Resting BVR was higher in ICD patients compared with controls without structural heart disease. In ICD patients with nsVT, BVR increased significantly 1-minute pre-nsVT in ischemic cardiomyopathy (2.21 +/- 0.59 ms, versus 5 minutes pre-nsVT: 1.78 +/- 0.50 ms, P<0.001) and dilated cardiomyopathy (2.09 +/- 0.57 ms, versus 5-minutes pre-nsVT: 1.58 +/- 0.51 ms, P<0.001), but not in patients without nsVT. In multivariable Cox regression analysis, pre-nsVT BVR was a significant predictor for appropriate therapy during follow-up. Conclusions Baseline BVR is elevated and temporal changes in BVR predict imminent nsVT events in patients with ICD independent of underlying cause. Real-time BVR monitoring could be used to predict impending ventricular arrhythmia and allow preventive therapy to be incorporated into ICDs.