History

History and physical examinations findings often provide a clue regarding the underlying cardiac pathology leading to electrical alternans. For example, electrical alternans in the setting of hypotension or worsening dyspnea in patients with pericarditis would indicate the development of cardiac tamponade. Similarly, ST-T alternans in the setting of chest pain, diaphoresis, and dyspnea would indicate severe myocardial ischemia. T-wave alternans observed in the setting of palpitations and syncope would point toward an underlying ventricular arrhythmia.

Physical Examination

Physical examination should be directed toward diagnosis of the underlying cardiac etiology for electrical alternans. The classical Beck triad of jugular venous distention, hypotension, and muffled heart sounds, or any of its individual features could arise from cardiac tamponade. Additional pulsus paradoxus may be noted. The presence of added heart sounds and signs of fluid overload suggest an underlying cardiomyopathy or heart failure.

Differential Diagnoses

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Media Gallery

Electrical alternans. This electrocardiogram shows a typical alternate-beat QRS electrical alternans. Note that the QRS voltage is low.
Electrical alternans. This electrocardiogram reveals supraventricular tachycardia with alternans. Note the phasic nature to the QRS morphology, particularly in the rhythm strip in V1.
Electrical alternans. This electrocardiogram reveals macro-T wave alternans with switched polarity seen in all leads.
Electrical alternans. This electrocardiogram shows ventricular tachycardia from the right ventricular outflow tract (RVOT) region. Note the R wave alternans seen in the wide QRS complexes.

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Author

Bharat K Kantharia, MD, FRCP, FAHA, FACC, FESC, FHRS Clinical Professor of Medicine, Icahn School of Medicine at Mount Sinai; Cardiac Electrophysiologist, Mount Sinai Health System, New York-Presbyterian Healthcare System, Montefiore Medical Center, Lennox Hill Hospital

Bharat K Kantharia, MD, FRCP, FAHA, FACC, FESC, FHRS is a member of the following medical societies: American College of Cardiology, American Heart Association, Cardiac Electrophysiology Society, European Cardiac Arrhythmia Society, European Society of Cardiology, Heart Rhythm Society, Medical Society of the State of New York, Royal College of Physicians of Edinburgh, Royal College of Physicians of Ireland, Royal College of Physicians of London, Royal Society of Medicine, Texas Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Bharat Narasimhan, MD, MBBS Resident Physician, Department of Internal Medicine, Mount Sinai St Lukes and Mount Sinai West, Icahn School of Medicine at Mount Sinai

Disclosure: Nothing to disclose.

Arti N Shah, MD, MS, FACC, FACP, CEPS-AC, CEDS Assistant Professor of Medicine, Mount Sinai School of Medicine; Director of Electrophysiology, Elmhurst Hospital Center and Queens Hospital Center

Arti N Shah, MD, MS, FACC, FACP, CEPS-AC, CEDS is a member of the following medical societies: American Association of Cardiologists of Indian Origin, American College of Cardiology, American College of Physicians, American Heart Association, Cardiac Electrophysiology Society, European Heart Rhythm Society, European Society of Cardiology, Heart Rhythm Society, New York Academy of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven J Compton, MD, FACC, FACP, FHRS Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Physicians, American Heart Association, American Medical Association, Heart Rhythm Society, Alaska State Medical Association, American College of Cardiology

Disclosure: Nothing to disclose.

Chief Editor

Mikhael F El-Chami, MD Associate Professor, Department of Medicine, Division of Cardiology, Section of Electrophysiology, Emory University School of Medicine

Mikhael F El-Chami, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Heart Rhythm Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic; Boston Scientific, Biotronik<br/>Received research grants (as part of Multicenter studies) from Medtronic and Boston Scientific.

Additional Contributors

Amal Mattu, MD, FACEP, FAAEM Professor and Vice Chair, Department of Emergency Medicine, University of Maryland School of Medicine

Amal Mattu, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Eric Gorgon Shaw, MD, FACEP, FAAEM, FAWM Assistant Professor of Emergency Medicine, State University of New York Upstate Medical University

Eric Gorgon Shaw, MD, FACEP, FAAEM, FAWM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, International Society of Travel Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Electrical Alternans Clinical Presentation

History

Physical Examination

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