CLINICAL STUDY: ELECTROPHYSIOLOGY
A comparison of T-wave alternans, signal averaged electrocardiography and programmed ventricular stimulation for arrhythmia risk stratification
Michael R. Gold, MD, PhD, FACC*,
Daniel M. Bloomfield, MD, FACC ,
Kelley P. Anderson, MD, FACC ,
Nabil E. El-Sherif, MD, FACC ,
David J. Wilber, MD, FACC||,
William J. Groh, MD, FACC,
N. A. Mark Estes, III, MD, FACC#,
Elizabeth S. Kaufman, MD, FACC,
Mark L. Greenberg, MD, FACC** and
David S. Rosenbaum, MD, FACC**
* Department of Medicine, Division of Cardiology, University of Maryland Medical System, Baltimore, Maryland, USA
Columbia Presbyterian Medical Center, New York, New York, USA
University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
Veterans Affairs Medical Center, Brooklyn, New York, USA
|| University of Chicago Hospitals, Chicago, Illinois, USA
# New England Medical Center, Boston, Massachusetts, USA
** MetroHealth Campus, Case Western Reserve University, Cleveland, Ohio, USA
Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
Manuscript received February 22, 2000;
revised manuscript received August 2, 2000,
accepted August 11, 2000.
Reprint requests and correspondence: Dr. Michael R. Gold, Division of Cardiology, N3W77, University of Maryland Medical System, 22 South Greene Street, Baltimore, Maryland 21201
MGold{at}medicine.umaryland.edu
OBJECTIVES
The goal of this study was to compare T-wave alternans (TWA), signal-averaged electrocardiography (SAECG) and programmed ventricular stimulation (EPS) for arrhythmia risk stratification in patients undergoing electrophysiology study.
BACKGROUND
Accurate identification of patients at increased risk for sustained ventricular arrhythmias is critical to prevent sudden cardiac death. T-wave alternans is a heart rate dependent measure of repolarization that correlates with arrhythmia vulnerability in animal and human studies. Signal-averaged electrocardiography and EPS are more established tests used for risk stratification.
METHODS
This was a prospective, multicenter trial of 313 patients in sinus rhythm who were undergoing electrophysiologic study. T-wave alternans, assessed with bicycle ergometry, and SAECG were measured before EPS. The primary end point was sudden cardiac death, sustained ventricular tachycardia, ventricular fibrillation or appropriate implantable defibrillator (ICD) therapy, and the secondary end point was any of these arrhythmias or all-cause mortality.
RESULTS
Kaplan-Meier survival analysis of the primary end point showed that TWA predicted events with a relative risk of 10.9, EPS had a relative risk of 7.1 and SAECG had a relative risk of 4.5. The relative risks for the secondary end point were 13.9, 4.7 and 3.3, respectively (p < 0.05). Multivariate analysis of 11 clinical parameters identified only TWA and EPS as independent predictors of events. In the prespecified subgroup with known or suspected ventricular arrhythmias, TWA predicted primary end points with a relative risk of 6.1 and secondary end points with a relative risk of 8.0.
CONCLUSIONS
T-wave alternans is a strong independent predictor of spontaneous ventricular arrhythmias or death. It performed as well as programmed stimulation and better than SAECG in risk stratifying patients for life-threatening arrhythmias.
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Abbreviations and Acronyms
| | EPS | = programmed ventricular stimulation during electrophysiology study | | ICD | = implantable cardioverter-defibrillator | | SAECG | = signal averaged electrocardiogram | | TWA | = T-wave alternans | | VTE | = ventricular tachyarrhythmic event |
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