Does Microvolt T-Wave Alternans Testing Predict Ventricular Tachyarrhythmias in Patients With Ischemic Cardiomyopathy and Prophylactic Defibrillators?

• Published in: Journal of the American College of Cardiology Vol. 52; no. 20; pp. 1607 - 1615
• Main Authors: Chow, Theodore, MD, FACC, Kereiakes, Dean J., MD, FACC, Onufer, John, MD, Woelfel, Alan, MD, Gursoy, Sinan, MD, Peterson, Brett J., BS, Brown, Mark L., PhD, Pu, Wenji, PhD, Benditt, David G., MD
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 11.11.2008
• Subjects: Cardiovascular; defibrillator therapy; Internal Medicine; risk stratification; sudden death; T-wave alternans; ventricular arrhythmias; CHF; risk stratification; ventricular tachyarrhythmic event; CRT; VTE; LVEF; microvolt T-wave alternans; T-wave alternans; HR; sudden cardiac death; left ventricular ejection fraction; sudden death; New York Heart Association; MTWA; congestive heart failure; implantable cardioverter-defibrillator; NYHA; cardiac resynchronization therapy; CI; ICD; defibrillator therapy; ventricular arrhythmias; SCD; hazard ratio; confidence interval
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2008.08.018

Objectives The purpose of this trial was to determine whether microvolt T-wave alternans (MTWA) predicts ventricular tachyarrhythmic events (VTEs) in post-myocardial infarction patients with left ventricular ejection fraction (LVEF) ≤30%. Background Previous studies have established MTWA as a predictor for total and arrhythmic mortality, but its ability to identify prophylactic implantable cardioverter-defibrillator (ICD) recipients most likely to experience VTEs remains uncertain. Methods This prospective trial was conducted at 50 U.S. centers. Patients were eligible if they met MADIT-II (Multicenter Automatic Defibrillator Implantation Trial II) indications for device implant. All patients underwent MTWA testing followed by ICD implantation, with pre-specified programming to minimize the likelihood of therapies for non–life-threatening VTE. Minimum follow-up was 2 years with annual MTWA testing. Initially indeterminate MTWA tests were repeated. Results Analyses were conducted on 575 patients (84% male; average age ± SD = 65 ± 11 years; average LVEF ± SD = 0.24 ± 0.05). The final distribution of MTWA results were: MTWA positive in 293 (51%), MTWA negative in 214 (37%), and indeterminate in 68 patients (12%). Over an average follow-up of 2.1 ± 0.9 years, there were 70 VTEs. A VTE occurred in 48 of 361 (13%, 6.3%/year) MTWA non-negative and 22 of 214 (10%, 5.0%/year) MTWA negative patients. A non-negative MTWA test result was not associated with VTE (hazard ratio: 1.26; 95% confidence interval: 0.76 to 2.09; p = 0.37), although total mortality was significantly increased (hazard ratio: 2.04; 95% confidence interval: 1.10 to 3.78; p = 0.02). Conclusions In MADIT-II–indicated ICD-treated patients, the risk of VTE does not differ according to MTWA classification, despite differences in total mortality. (MASTER I–Microvolt T Wave Alternans Testing for Risk Stratification of Post MI Patients; NCT00305240 )