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Can microvolt T-wave alternans testing reduce unnecessary defibrillator implantation?

Nature Clinical Practice Cardiovascular Medicine volume 2, pages 522–528 (2005)Cite this article

Abstract

The Multicenter Automatic Defibrillator Implantation Trial II (MADIT II) and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) have established that patients with a reduced ejection fraction gain an overall mortality benefit from prophylactic implantable cardioverter-defibrillator therapy. Only a small proportion of the patients in these studies, however, have received life-saving therapy from the defibrillator. Because defibrillator therapy is invasive and expensive, patients with a low ejection fraction would benefit from effective risk stratification so that defibrillator therapy was used only in those at significant risk. In this review, we analyze prospective clinical trials that have evaluated microvolt T-wave alternans (MTWA) testing as a predictor of ventricular tachyarrhythmic events in populations of patients similar to those studied in MADIT II or SCD-HeFT; that is, patients with a reduced ejection fraction who were not selected on the basis of a history of ventricular tachyarrhythmias. In these studies, the average annual rate of fatal and nonfatal ventricular tachyarrhythmic events among the patients who tested negative for MTWA was around 1%. This rate is so low that it is unlikely that such patients would benefit from implantable cardioverter-defibrillator therapy. The mortality, moreover, was lower among MTWA-negative patients who did not receive implantable defibrillators than that observed in the MADIT II and SCD-HeFT patients who received implantable cardioverter-defibrillators. In response, patients with a low ejection fraction who are being considered for implantable cardioverter-defibrillator therapy should undergo MTWA testing as part of their evaluation.

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Figure 1: Visible and microvolt T-wave alternans.
Figure 2: Mechanisms by which T-wave alternans is involved in the development of arrhythmias.
Figure 3: Representative report of microvolt T-wave alternans test.

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Acknowledgements

This work was supported by the US National Aeronautics and Space Administration, through grants from the National Space Biomedical Research Institute, and by an America Heart Association Beginning Grant-in-Aid (#0365304U) to AAA.

Author information

Authors and Affiliations

  1. an Instructor in Medicine at the Massachusetts General Hospital, MA, USA

    Antonis A Armoundas

  2. a Professor of Medicine and Cardiology at the Johann Wolfgang Goethe University, Germany

    Stefan H Hohnloser

  3. an Associate Professor of Medicine at the Kyorin University School of Medicine, Japan

    Takanori Ikeda

  4. the Whitaker Professor in Biomedical Engineering at the Massachusetts Institute of Technology, MA, USA

    Richard J Cohen

Authors
  1. Antonis A Armoundas
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  2. Stefan H Hohnloser
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  3. Takanori Ikeda
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  4. Richard J Cohen
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Correspondence to Richard J Cohen.

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Competing interests

RJ Cohen is a consultant and board member for Cambridge Heart Inc., a manufacturer of equipment for the measurement of microvolt T-wave alternans, and has a financial interest in the company. He is also a consultant for Medtronic Inc., a manufacturer of implantable cardioverter-defibrillators.

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Armoundas, A., Hohnloser, S., Ikeda, T. et al. Can microvolt T-wave alternans testing reduce unnecessary defibrillator implantation?. Nat Rev Cardiol 2, 522–528 (2005). https://doi.org/10.1038/ncpcardio0323

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