Macroscopic T Wave Alternans --Unusual Presentation in Cirrhotic Patients.

Clinical Key MessageT-wave alternans (TWA) refers to the alternating pattern observed in the ST segment, T wave, and U wave, and is also known as repolarization alterations.Macroscopic TWA has been observed in patients with various conditions such as ischemia, electrolyte imbalances, long QT syndrome, and during the transition from tachycardia to normal rhythm.Here we present a 32-year-old man with prior history of chronic alcohol abuse and end-stage liver failure was admitted to the hospital with hemorrhagic shock.After several days of hospitalization, his condition was further complicated by cardiac arrest due to Torsades de Pointes (TdP) and prolonged QTc interval with Macroscopic T-wave alternans (MWTA), necessitating defibrillation.Blood work revealed high potassium (K) levels of 6.3 mmol/L and low magnesium (Mg) levels of 1.7 mg/dL.The patient received multiple doses of intravenous magnesium and intravenous insulin with bicarbonate.Despite initial management, the QT interval continued to prolong, leading to the initiation of a transvenous pacemaker and intravenous isoproterenol to acutely shorten the QT interval.Coronary angiogram results ruled out the presence of coronary artery disease.Medications that prolonged the QT interval were reviewed and discontinued.With supportive treatment, the T-wave alternans resolved, and the QTc interval normalized.A previous electrocardiogram conducted prior to the onset of liver failure confirmed a normal QT interval.Due to ongoing alcohol abuse, the patient was not eligible for liver transplantation and was eventually discharged to hospice care.