STATE-OF-THE-ART PAPER
T-Wave Alternans and the Susceptibility to Ventricular Arrhythmias
Sanjiv M. Narayan, MB, MD, FACC*, ,*
* University of California, San Diego
Veterans Affairs Medical Center, La Jolla, California.
Manuscript received May 9, 2005;
revised manuscript received July 20, 2005,
accepted August 1, 2005.
* Reprint requests and correspondence: Dr. Sanjiv M. Narayan, San Diego VA Healthcare System, University of California San Diego, Whitaker Institute for Biomedical Engineering, Cardiology, 111A, 3350 La Jolla Village Drive, San Diego, California 92161. (Email: snarayan{at}ucsd.edu).
T-wave alternans (TWA) reflects beat-to-beat fluctuations in the electrocardiographic T-wave, and is associated with dispersion of repolarization and the mechanisms for sudden cardiac arrest (SCA). This review examines the bench-to-bedside literature that, over decades, has linked alternans of repolarization in cellular, whole-heart, and human studies with spatial dispersion of repolarization, alternans of cellular action potential, and fluctuations in ionic currents that may lead to ventricular arrhythmias. Collectively, these studies provide a foundation for the clinical use of TWA to reflect susceptibility to ventricular arrhythmias in several disease states. This review then provides a contemporary evidence-based framework for the use of TWA to enhance risk stratification for SCA, identifying populations for whom TWA is best established, those for whom further studies are required, and areas for additional investigation.
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Abbreviations and Acronyms
| | APD = action potential duration | | DI = diastolic interval | | ECG = electrocardiography | | EPS = electrophysiologic study | | HCM = hypertrophic cardiomyopathy | | ICD = implantable cardioverter-defibrillator | | LQTS = long QT syndrome | | LV = left ventricular | | LVEF = left ventricular ejection fraction | | MADIT = Multicenter Automatic Defibrillator Trial | | MASTERS = Microvolt T-wave Alternans Testing for Risk Stratification of post-MI patients | | MI = myocardial infarction | | MMA = Modified Moving Average | | MUSTT = Multicenter Unsustained Tachycardia Trial | | NICM = non-ischemic cardiomyopathy | | RR = relative risk | | SAECG = signal-averaged ECG | | SCA = sudden cardiac arrest | | TWA = T-wave alternans | | VF = ventricular fibrillation | | VT = ventricular tachycardia |
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