title: Anger-induced T-wave alternans predicts future ventricular arrhythmias in patients with implantable cardioverter-defibrillators.
abstract: OBJECTIVE
  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.
authors.affiliation: Yale University School of Medicine, New Haven, Connecticut, USA.
authors.forename: Rachel
authors.initials: R
authors.lastname: Lampert
authors.forename: Vladimir
authors.initials: V
authors.lastname: Shusterman
authors.forename: Matthew
authors.initials: M
authors.lastname: Burg
authors.forename: Craig
authors.initials: C
authors.lastname: McPherson
authors.forename: William
authors.initials: W
authors.lastname: Batsford
authors.forename: Anna
authors.initials: A
authors.lastname: Goldberg
authors.forename: Robert
authors.initials: R
authors.lastname: Soufer
mesh_terms: D000368:Aged; D000786:Anger; D002311:Cardiomyopathy, Dilated / Q000150:complications; D003324:Coronary Artery Disease / Q000150:complications; D017147:Defibrillators, Implantable; D005260:Female; D006339:Heart Rate; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D012307:Risk Factors; D013315:Stress, Psychological / Q000150:complications*; D017180:Tachycardia, Ventricular / Q000453:epidemiology / Q000209:etiology / Q000523:psychology*; D014481:United States / Q000453:epidemiology; D014693:Ventricular Fibrillation / Q000453:epidemiology / Q000209:etiology / Q000523:psychology*