T-wave Heterogeneity is Superior to QTc in 12-Lead ECG in Detection of Cardiac Electrical Instability at EMU Admission
Trudy Pang1, Wan Yee Kong1, Anthony Tran1, Calvin Yu1, Yvo Rodriguez-Linares1, Bruce Nearing2, Steven Schachter3, Richard Verrier2
1Neurology, 2Medicine, Beth Israel Deaconess Medical Center (BIDMC), 3Consortia for Improving Medicine with Innovation & Technology (CIMIT)
Objective:
  • We investigated whether R-wave and T-wave heterogeneity (RWH, TWH) in 12-lead ECGs at epilepsy monitoring unit (EMU) admission is superior to QT-interval prolongation in detecting cardiac electrical instability in epilepsy patients.
Background:
  • The Epileptic Heart, detectable by elevations in RWH and TWH, results from chronic epilepsy-induced cardiac injury leading to electrical and mechanical dysfunction, and is associated with elevated risk for sudden cardiac death (SCD).  QT-interval prolongation is also associated with increased all-cause mortality in epilepsy and the general population.
Design/Methods:
  • In all 132 patients with EMU admission day 12-lead ECGs between 2017 and 2021 at our institution, we determined corrected QT (QTc) intervals from clinical records and RWH and TWH levels by second central moment analysis, in patients with generalized tonic-clonic seizures (GTCS), focal seizures (FS), and nonepileptic seizures (NES) only.
Results:
  • Patients with GTCS (n=66) and FS (n=36) had significantly elevated RWH of 168±9.9 µV (p< 0.03) and 165±12 µV (p< 0.04) respectively, compared to those with NES (n=30) (125±10.5 µV), as previously reported.  TWH was also abnormally elevated in patients with GTCS (83±5.9 µV, p< 0.05), and FS (79±4.8 µV, p<0.02), compared to NES (61±5.0 µV).  Both RWH and TWH were within the normal range in patients with NES only.  By comparison, mean QTc was in the normal range for patients with epilepsy and those with NES, at 422±3 ms and 436±5 ms, respectively.
Conclusions:

  • This is the first study to demonstrate the superior capacity of RWH and TWH to detect cardiac electrical instability in epilepsy patients compared to QTc in 12-lead ECGs.  These observations suggest that RWH and TWH may be more sensitive markers of potential susceptibility to SCD or sudden unexpected death in epilepsy (SUDEP). ECGs are clinically readily available and these markers could provide a means to monitor sudden death risk longitudinally.

10.1212/WNL.0000000000202482