CLINICAL RESEARCH: HEART RHYTHM DISORDERS
Prognostic Utility of Microvolt T-Wave Alternans in Risk Stratification of Patients With Ischemic Cardiomyopathy
Theodore Chow, MD, FACC*,
Dean J. Kereiakes, MD, FACC*,
Cheryl Bartone, RN*,
Terri Booth, RN*,
Edward J. Schloss, MD, FACC*,
Theodore Waller, MD, FACC*,
Eugene S. Chung, MD*,
Santosh Menon, MD*,
Brahmajee K. Nallamothu, MD, MPH and
Paul S. Chan, MD, MSc,*
* The Lindner Clinical Trial Center at the Christ Hospital and the Ohio Heart & Vascular Center, Cincinnati, Ohio
VA Health Services Research & Development and University of Michigan Medical School, Ann Arbor, Michigan.
Manuscript received August 16, 2005;
revised manuscript received October 25, 2005,
accepted November 1, 2005.
* Reprint requests and correspondence: Dr. Paul S. Chan, Cardiology (111-A), VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, Michigan 48105. (Email: paulchan{at}umich.edu).
OBJECTIVES: The purpose of this study was to assess if microvolt T-wave alternans (MTWA) is an independent predictor of mortality in patients with ischemic cardiomyopathy.
BACKGROUND: Microvolt T-wave alternans has been proposed as an effective tool for identifying high-risk patients with ischemic cardiomyopathy who are likely to benefit from implantable cardioverter-defibrillator (ICD) therapy. However, earlier studies have been limited in their ability to control for baseline differences between MTWA-negative and -non-negative (positive and indeterminate) patients.
METHODS: We enrolled 768 consecutive patients with ischemic cardiomyopathy (left ventricular ejection fraction  35%) and no prior history of ventricular arrhythmia. All patients underwent baseline MTWA testing and were classified as MTWA negative or non-negative. Multivariable Cox regression analyses, stratified by ICD status, were used to determine the association between MTWA testing and mortality after adjusting for demographic, clinical, and treatment differences between MTWA-negative and -non-negative patients.
RESULTS: We identified 514 (67%) patients with a non-negative MTWA test. After multivariable adjustment, a non-negative MTWA test was associated with a significantly higher risk for all-cause (stratified hazard ratio [HR] = 2.24 [95% confidence interval 1.34 to 3.75]; p = 0.002) and arrhythmic mortality (stratified HR = 2.29 [1.00 to 5.24]; p = 0.049) but not for nonarrhythmic mortality (stratified HR = 1.77 [0.84 to 3.74]; p = 0.13). In subgroup analyses, a non-negative MTWA test was also associated with a higher risk for all-cause mortality in patients with ejection fractions 30% (stratified HR = 2.10 [1.18 to 3.73]; p = 0.01) and after excluding those with indeterminate MTWA tests (stratified HR = 2.08 [1.18 to 3.66]; p = 0.01).
CONCLUSIONS: Microvolt T-wave alternans is a strong and independent predictor of all-cause and arrhythmic mortality in patients with ischemic cardiomyopathy.
|
Abbreviations and Acronyms
| | CI = confidence interval | | HR = hazard ratio | | ICD = implantable cardioverter-defibrillator | | LVEF = left ventricular ejection fraction | | MADIT-II = second Multicenter Automatic Defibrillator Implantation Trial | | MTWA = microvolt T-wave alternans | | SCD = sudden cardiac death | | SCD-HeFT = Sudden Cardiac Death in Heart Failure Trial |
|
This article has been cited by other articles:
|
|
|
|
 
F. M. Merchant and A. A. Armoundas
Role of Substrate and Triggers in the Genesis of Cardiac Alternans, From the Myocyte to the Whole Heart: Implications for Therapy
Circulation,
January 24, 2012;
125(3):
539 - 549.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. L. Verrier, T. Klingenheben, M. Malik, N. El-Sherif, D. V. Exner, S. H. Hohnloser, T. Ikeda, J. P. Martinez, S. M. Narayan, T. Nieminen, et al.
Microvolt T-wave alternans physiological basis, methods of measurement, and clinical utility-consensus guideline by international society for holter and noninvasive electrocardiology.
J. Am. Coll. Cardiol.,
September 20, 2011;
58(13):
1309 - 1324.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Bonapace, G. Targher, G. Molon, A. Rossi, A. Costa, L. Zenari, L. Bertolini, D. Cian, L. Lanzoni, and E. Barbieri
Relationship Between Early Diastolic Dysfunction and Abnormal Microvolt T-Wave Alternans in Patients With Type 2 Diabetes
Circ Cardiovasc Imaging,
July 1, 2011;
4(4):
408 - 414.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. K. Patel, P. B. Mark, C. Halliday, T. Steedman, H. J. Dargie, S. M. Cobbe, and A. G. Jardine
Microvolt T-Wave Alternans in End-Stage Renal Disease Patients--Associations with Uremic Cardiomyopathy
Clin. J. Am. Soc. Nephrol.,
March 1, 2011;
6(3):
519 - 527.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Liew
Prediction of sudden arrhythmic death following acute myocardial infarction
Heart,
July 1, 2010;
96(14):
1086 - 1094.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. M. Marcus, E. Keung, and M. M. Scheinman
The Year in Review of Clinical Cardiac Electrophysiology
J. Am. Coll. Cardiol.,
August 25, 2009;
54(9):
777 - 787.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. P. Slawnych, T. Nieminen, M. Kahonen, K. M. Kavanagh, T. Lehtimaki, D. Ramadan, J. Viik, S. G. Aggarwal, R. Lehtinen, L. Ellis, et al.
Post-Exercise Assessment of Cardiac Repolarization Alternans in Patients With Coronary Artery Disease Using the Modified Moving Average Method
J. Am. Coll. Cardiol.,
March 31, 2009;
53(13):
1130 - 1137.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Bauer, P. Barthel, R. Schneider, K. Ulm, A. Muller, A. Joeinig, R. Stich, A. Kiviniemi, K. Hnatkova, H. Huikuri, et al.
Improved Stratification of Autonomic Regulation for risk prediction in post-infarction patients with preserved left ventricular function (ISAR-Risk)
Eur. Heart J.,
March 1, 2009;
30(5):
576 - 583.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
O. Costantini, S. H. Hohnloser, M. M. Kirk, B. B. Lerman, J. H. Baker II, B. Sethuraman, M. M. Dettmer, D. S. Rosenbaum, and for the ABCD Trial Investigators
The ABCD (Alternans Before Cardioverter Defibrillator) Trial: Strategies Using T-Wave Alternans to Improve Efficiency of Sudden Cardiac Death Prevention
J. Am. Coll. Cardiol.,
February 10, 2009;
53(6):
471 - 479.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. K. Feld and P. Clopton
Comparability of Noninvasive Microvolt T-Wave Alternans Versus Invasive Ventricular Programmed Stimulation to Guide Implantable Cardioverter-Defibrillator Implantation in Patients at Risk of Sudden Death
J. Am. Coll. Cardiol.,
February 10, 2009;
53(6):
480 - 482.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. S. Chan, G. Soto, P. G. Jones, B. K. Nallamothu, Z. Zhang, W. S. Weintraub, and J. A. Spertus
Patient Health Status and Costs in Heart Failure: Insights From the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS)
Circulation,
January 27, 2009;
119(3):
398 - 407.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. S. Chan, B. K. Nallamothu, J. A. Spertus, F. A. Masoudi, C. Bartone, D. J. Kereiakes, and T. Chow
Impact of Age and Medical Comorbidity on the Effectiveness of Implantable Cardioverter-Defibrillators for Primary Prevention
Circ Cardiovasc Qual Outcomes,
January 1, 2009;
2(1):
16 - 24.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Authors/Task Force Members, F. Van de Werf, J. Bax, A. Betriu, C. Blomstrom-Lundqvist, F. Crea, V. Falk, G. Filippatos, K. Fox, K. Huber, et al.
Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology:
Eur. Heart J.,
December 1, 2008;
29(23):
2909 - 2945.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Chow, D. J. Kereiakes, J. Onufer, A. Woelfel, S. Gursoy, B. J. Peterson, M. L. Brown, W. Pu, D. G. Benditt, and on behalf of the MASTER Trial Investigators
Does Microvolt T-Wave Alternans Testing Predict Ventricular Tachyarrhythmias in Patients With Ischemic Cardiomyopathy and Prophylactic Defibrillators?: The MASTER (Microvolt T Wave Alternans Testing for Risk Stratification of Post-Myocardial Infarction Patients) Trial
J. Am. Coll. Cardiol.,
November 11, 2008;
52(20):
1607 - 1615.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. S. Rosenbaum
T-Wave Alternans in the Sudden Cardiac Death in Heart Failure Trial Population: Signal or Noise?
Circulation,
November 11, 2008;
118(20):
2015 - 2018.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. R. Gold, J. H. Ip, O. Costantini, J. E. Poole, S. McNulty, D. B. Mark, K. L. Lee, and G. H. Bardy
Role of Microvolt T-Wave Alternans in Assessment of Arrhythmia Vulnerability Among Patients With Heart Failure and Systolic Dysfunction: Primary Results From the T-Wave Alternans Sudden Cardiac Death in Heart Failure Trial Substudy
Circulation,
November 11, 2008;
118(20):
2022 - 2028.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. A. Noseworthy and C. Newton-Cheh
Genetic Determinants of Sudden Cardiac Death
Circulation,
October 28, 2008;
118(18):
1854 - 1863.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. J. Goldberger, M. E. Cain, S. H. Hohnloser, A. H. Kadish, B. P. Knight, M. S. Lauer, B. J. Maron, R. L. Page, R. S. Passman, D. Siscovick, et al.
American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society Scientific Statement on Noninvasive Risk Stratification Techniques for Identifying Patients at Risk for Sudden Cardiac Death: A Scientific Statement From the American Heart Association Council on Clinical Cardiology Committee on Electrocardiography and Arrhythmias and Council on Epidemiology and Prevention
J. Am. Coll. Cardiol.,
September 30, 2008;
52(14):
1179 - 1199.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. J. Goldberger, M. E. Cain, S. H. Hohnloser, A. H. Kadish, B. P. Knight, M. S. Lauer, B. J. Maron, R. L. Page, R. S. Passman, D. Siscovick, et al.
American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society Scientific Statement on Noninvasive Risk Stratification Techniques for Identifying Patients at Risk for Sudden Cardiac Death: A Scientific Statement From the American Heart Association Council on Clinical Cardiology Committee on Electrocardiography and Arrhythmias and Council on Epidemiology and Prevention
Circulation,
September 30, 2008;
118(14):
1497 - 1518.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Malik
Arrhythmic substrate
Heart,
April 1, 2008;
94(4):
402 - 403.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. C. Myles, C. E. Jackson, I. Tsorlalis, M. C. Petrie, J. J. V. McMurray, and S. M. Cobbe
Is Microvolt T-Wave Alternans the Answer to Risk Stratification in Heart Failure?
Circulation,
December 18, 2007;
116(25):
2984 - 2991.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. A. Salerno-Uriarte, G. M. De Ferrari, C. Klersy, R. F.E. Pedretti, M. Tritto, L. Sallusti, L. Libero, G. Pettinati, G. Molon, A. Curnis, et al.
Prognostic Value of T-Wave Alternans in Patients With Heart Failure Due to Nonischemic Cardiomyopathy: Results of the ALPHA Study
J. Am. Coll. Cardiol.,
November 6, 2007;
50(19):
1896 - 1904.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Nieminen, T. Lehtimaki, J. Viik, R. Lehtinen, K. Nikus, T. Koobi, K. Niemela, V. Turjanmaa, W. Kaiser, H. Huhtala, et al.
T-wave alternans predicts mortality in a population undergoing a clinically indicated exercise test
Eur. Heart J.,
October 1, 2007;
28(19):
2332 - 2337.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. V.A. Boersma
T-wave alternans: predicting the unpredictable?
Eur. Heart J.,
October 1, 2007;
28(19):
2303 - 2304.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Klingenheben
Microvolt T-Wave Alternans for Arrhythmia Risk Stratification in Left Ventricular Dysfunction: Which Patients Benefit?
J. Am. Coll. Cardiol.,
July 10, 2007;
50(2):
174 - 175.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. J. Cantillon, K. M. Stein, S. M. Markowitz, S. Mittal, B. K. Shah, D. P. Morin, E. S. Zacks, M. Janik, S. Ageno, A. C. Mauer, et al.
Predictive Value of Microvolt T-Wave Alternans in Patients With Left Ventricular Dysfunction
J. Am. Coll. Cardiol.,
July 10, 2007;
50(2):
166 - 173.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. M. Scheinman and E. Keung
The Year in Clinical Cardiac Electrophysiology
J. Am. Coll. Cardiol.,
May 22, 2007;
49(20):
2061 - 2069.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. J. Selvaraj, P. Picton, K. Nanthakumar, and V. S. Chauhan
Steeper restitution slopes across right ventricular endocardium in patients with cardiomyopathy at high risk of ventricular arrhythmias
Am J Physiol Heart Circ Physiol,
March 1, 2007;
292(3):
H1262 - H1268.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. N. DeMaria, O. Ben-Yehuda, G. K. Feld, G. S. Ginsburg, B. H. Greenberg, W. Y.W. Lew, J. A.C. Lima, A. S. Maisel, J. Narula, D. J. Sahn, et al.
Highlights of the Year in JACC 2006
J. Am. Coll. Cardiol.,
January 30, 2007;
49(4):
509 - 527.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. M. Narayan
T-Wave Alternans and Human Ventricular Arrhythmias: What Is the Link?
J. Am. Coll. Cardiol.,
January 23, 2007;
49(3):
347 - 349.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. M. Russo and F. E. Marchlinski
Should Microvolt T-Wave Alternans Be Utilized Routinely in Selecting Patients for Prophylactic Implantable Cardioverter-Defibrillator Insertion in the Setting of Ischemic Heart Disease?
J. Am. Coll. Cardiol.,
January 2, 2007;
49(1):
59 - 61.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Chow, D. J. Kereiakes, C. Bartone, T. Booth, E. J. Schloss, T. Waller, E. Chung, S. Menon, B. K. Nallamothu, and P. S. Chan
Microvolt T-Wave Alternans Identifies Patients With Ischemic Cardiomyopathy Who Benefit From Implantable Cardioverter-Defibrillator Therapy
J. Am. Coll. Cardiol.,
January 2, 2007;
49(1):
50 - 58.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Klingenheben
Arrhythmia Risk Prediction in Patients With Preserved Left Ventricular Function: The Final Frontier?
J. Am. Coll. Cardiol.,
December 5, 2006;
48(11):
2275 - 2276.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Developed in Collaboration With the European Heart, D. P. Zipes, A. J. Camm, M. Borggrefe, A. E. Buxton, B. Chaitman, M. Fromer, G. Gregoratos, G. Klein, A. J. Moss, et al.
ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death)
J. Am. Coll. Cardiol.,
September 5, 2006;
48(5):
e247 - e346.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Writing Committee Members, D. P. Zipes, A. J. Camm, M. Borggrefe, A. E. Buxton, B. Chaitman, M. Fromer, G. Gregoratos, G. Klein, A. J. Moss, et al.
ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: A report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society
Europace,
September 1, 2006;
8(9):
746 - 837.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. S. Chan, K. Stein, T. Chow, M. Fendrick, J. T. Bigger, and S. Vijan
Cost-Effectiveness of a Microvolt T-Wave Alternans Screening Strategy for Implantable Cardioverter-Defibrillator Placement in the MADIT-II-Eligible Population
J. Am. Coll. Cardiol.,
July 4, 2006;
48(1):
112 - 121.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Microvolt T-Wave Alternans Testing: Ready for Prime Time?
Journal Watch Cardiology,
June 28, 2006;
2006(628):
2 - 2.
[Full Text]
|
|
|
|
