Fixed coupling: different mechanisms revealed by exercise-induced changes in cycle length
Fixed coupled ventricular premature depolarizations (VPDs) are usually considered reentrant; recent experimental models have demonstrated that parasystolic rhythms may also appear in fixed coupled patterns. To analyze the mechanisms of fixed coupled VPDs, 60 exercise tests were chosen to evaluate the response of VPD coupling intervals to changes in cycle length of the dominant supraventricular rhythm. Selection criteria included the presence of frequent, unifocal VPDs that were fixed coupled
... riation < 80 msec) at any one cycle length, with the persistence of VPDs at several different cycle lengths. Three patterns of response of coupling intervals to changes in cycle length were noted: 1) 32 patients with a direct linear relation (r > 0.9) of coupling intervals to cycle length; 2) 16 patients with coupling intervals fixed, independent of cycle length; and 3) 12 patients with no consistent relation over a wide range of cycle lengths. Two patients in group 2 and four in group 3 fulfilled criteria for parasystole with interectopic intervals that remained constant at different cycle lengths. These results suggest that VPDs in group I are reentrant, while some patients with group 2 or 3 responses have evidence for parasystolic rhythms. We conclude that 1) fixed coupling of VPDs is not diagnostic of reentry, and 2) changes in cycle length induced with exercise may be useful in the analysis of mechanisms of VPDs. FIXED COUPLED VENTRICULAR premature depolarizations (VPDs) are common, and have been considered a marker for reentry. -3 Recent clinical observations and experimental evidence, however, suggest that parasystolic rhythms may also manifest fixed coupling under suitable conditions.4'6 The present study was undertaken to determine whether changes in heart rate occurring during exercise testing would reveal mechanisms for fixed coupled VPDs not apparent on either resting ECGs or on longer rhythm strips with the usual narrow ranges of heart rates. Materials and Methods Exercise tests of 60 patients were selected on the basis of: 1) the presence of frequent unifocal VPDs; 2) fixed coupling of at least three VPDs to preceding supraventricular depolarizations during each of 5 minutes of pre-exercise electrocardiographic recording; and 3) the persistence of frequent VPDs with exercise. Pre-exercise ECG tracings were taken supine, standing and at rest with hyperventilation. Three simultaneous leads (standard lead II, V, and V,; or V, V4 and V,) were monitored continuously.