Stochastic pacing reveals the propensity to cardiac action potential alternans and uncovers its underlying dynamics

Beat-to-beat alternation (alternans) of the cardiac action potential duration is known to precipitate life-threatening arrhythmias and can be driven by the kinetics of voltage-gated membrane currents or by instabilities in intracellular calcium fluxes. To prevent alternans and associated arrhythmias, suitable markers must be developed to quantify the susceptibility to alternans; previous theoretical studies showed that the eigenvalue of the alternating eigenmode represents an ideal marker of alternans. Using rabbit ventricular myocytes, we show that this eigenvalue can be estimated in practice by pacing these cells at intervals varying stochastically. We also show that stochastic pacing permits the estimation of further markers distinguishing between voltage-driven and calcium-driven alternans. Our study opens the perspective to use stochastic pacing during clinical investigations and in patients with implanted pacing devices to determine the susceptibility to, and the type of alternans, which are both important to guide preventive or therapeutic measures.AbstractAlternans of the cardiac action potential (AP) duration (APD) is a well-known arrhythmogenic mechanism. APD depends on several preceding diastolic intervals (DIs) and APDs, which complicates the prediction of alternans. Previous theoretical studies pinpointed a marker called (alt) that directly quantifies how an alternating perturbation persists over successive APs. When the propensity to alternans increases, (alt) decreases from 0 to -1. Our aim was to quantify (alt) experimentally using stochastic pacing and to examine whether stochastic pacing allows discriminating between voltage-driven and Ca2+-driven alternans. APs were recorded in rabbit ventricular myocytes paced at cycle lengths (CLs) decreasing progressively and incorporating stochastic variations. Fitting APD with a function of two previous APDs and CLs permitted us to estimate (alt) along with additional markers characterizing whether the dependence of APD on previous DIs or CLs is strong (typical for voltage-driven alternans) or weak (Ca2+-driven alternans). During the recordings, (alt) gradually decreased from around 0 towards -1. Intermittent alternans appeared when (alt) reached -0.8 and was followed by sustained alternans. The additional markers detected that alternans was Ca2+ driven in control experiments and voltage driven in the presence of ryanodine. This distinction could be made even before alternans was manifest (specificity/sensitivity >80% for -0.4>(alt)>-0.5). These observations were confirmed in a mathematical model of a rabbit ventricular myocyte. In conclusion, stochastic pacing allows the practical estimation of (alt) to reveal the onset of alternans and distinguishes between voltage-driven and Ca2+-driven mechanisms, which is important since these two mechanisms may precipitate arrhythmias in different manners.