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

Chow, Theodore; Kereiakes, Dean J.; Onufer, John R.; Woelfel, Alan; Gürsoy, Sinan; Peterson, Brett J.; Brown, Mark L.; Pu, Wenji; Benditt, David G.; Investigators, Master Trial

doi:10.1016/j.jacc.2008.08.018

Cited by 179 publications

(83 citation statements)

References 30 publications

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“…15 EPS has also been assessed in 2 large, multicenter, contemporary studies, both performed within the subacute time after MI. The Alternans Before Cardioverter Defibrillator (ABCD) trial enrolled patients with ischemic cardiomyopathy and demonstrated that EPS significantly predicted the arrhythmic Randomized ICD trials: survival benefit in patients with LVEF ≤30% (5.6% absolute mortality reduction) 16 Electrophysiology study Randomized ICD trial: nonsignificant survival benefit 27 Observational ICD studies: positive EPS predicts arrhythmia; 28,29 negative EPS predicts survival without an ICD 29 Randomized ICD trials: survival benefit in EPS-positive patients (combined with LVEF; 23% and 31% absolute mortality reduction) 14,15 Microvolt T-wave alternans No randomized trials Observational study: nonpredictive of arrhythmic death 48 No randomized trials Observational studies: predictive of arrhythmic death [48][49][50] Autonomic dysfunction: HRV or resting tachycardia Randomized ICD trials: no survival benefit (combined with LVEF) 12,17 Observational studies: predictive of arrhythmic death 51 No randomized trials Observational studies: predictive of arrhythmic death [51][52][53][54] Signal-averaged ECG No randomized trials Observational study: nonpredictive of arrhythmic death 55 Randomized ICD trial: no survival benefit (combined with LVEF) 56 …”

Section: Electrophysiology Studymentioning

confidence: 99%

“…However, the Microvolt T Wave Alternans Testing for Risk Stratification of Post-Myocardial Infarction Patients (MASTER) trial, which also assessed MTWA remote after MI, found that it was positive in 51% of patients with a low positive predictive value for arrhythmia. 49 The Risk Estimation Following Infarction, Noninvasive Evaluation (REFINE) study performed several noninvasive risk stratification tests, including MTWA, in both the early (2-4 weeks) and subacute (10-14 weeks) periods after acute MI. 48 The REFINE investigators found that no noninvasive marker, including MTWA, predicted the outcome of cardiac death or resuscitated cardiac arrest when performed early after MI.…”

Section: Microvolt T-wave Alternansmentioning

confidence: 99%

“…Použití autonomní dysfunkce jako markeru zvýšeného rizika NSS v randomizovaných studiích DINAMIT a IRIS se do přínosu z hlediska zitivní prediktivní hodnotou pro arytmie. 49 Ve studii REFINE (Risk Estimation Following Infarction, Noninvasive Evaluation) bylo provedeno několik neinvazivních vyšetření pro stratifi kaci rizika, včetně použití MTWA, jak v časném (2-4 tý-dny), tak subakutním (10-14 týdnů) období po akutním IM. 48 Investigátoři studie REFINE zjistili, že žádný neinvazivní marker včetně MTWA, pokud bylo vyšetření provedeno časně po IM, nepredikoval úmrtí z kardiálních příčin ani resuscitovanou srdeční zástavu.…”

Section: Variabilita Srdeční Frekvence a Zvýšení Klidové Srdeční Frekunclassified

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Sudden Cardiac Death Early After Myocardial Infarction

2014

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The issue of SCD primary prevention early after MI remains unresolved. The focus is now firmly centered on the elucidation of risk stratification tests that effectively select patients at high risk of SCD who benefit from early ICD implantation. Zaman and Kovoor Primary Prevention of SCD Early After MI 2429A summary of major risk stratification tests currently used to identify patients at high risk of SCD is given in Table 2. LV DysfunctionImpaired LVEF, one of the most powerful predictors of survival, 64 has been shown to identify patients who derive a mortality benefit from an ICD when implanted predominantly in the remote period after MI. 16,65 However, there are major concerns with the use of LVEF alone as a risk stratifier to guide ICD implantation. One such concern is the low specificity of LVEF for selecting patients who experience arrhythmic versus nonarrhythmic death. In the MADIT II trial, the use of LVEF ≤30% alone to stratify patients for an ICD resulted in relatively small absolute improvement in mortality with low therapeutic efficiency (15-17 defibrillators per life saved). 66 Another concern is the sensitivity of LVEF, given that a large proportion of SCDs still occur in patients with preserved LV function. VALIANT demonstrated that, although the risk of SCD is greatest in patients with severe dysfunction (LVEF ≤30%), almost half of all sudden deaths occur in patients with a higher ejection fraction (LVEF, 31%-40%). 5 The use of LVEF as a risk stratification tool has been tested in the early post-MI stage in the DINAMIT and IRIS trials, which selected patients with LVEF ≤35% and ≤40%, respectively, and failed to show a benefit of early ICD implantation. 12,17 The major limitation with the use of an early LVEF cutoff is the phenomenon of myocardial stunning with variable and unpredictable recovery of LV function after MI. This is especially relevant in the contemporary era of primary PCI for STEMI. Of STEMI patients with LVEF ≤40% at day 3, 24% will improve to have an LVEF >40% at 6 months with a mean 6% relative improvement. 67 Hence, although LV function will invariably be incorporated into risk stratification models for the prevention of SCD, it is clear that other tests are required to adequately select high-risk patients early after MI. RV DysfunctionAlthough impaired LV function has been studied extensively as a predictor of mortality and arrhythmic death, RV dysfunction has been largely overlooked. We know from the VALIANT study that almost 50% of arrhythmic deaths occur in patients with a preserved LVEF.5 RV involvement in inferior MI has been shown to be a predictor of morbidity and mortality, with a higher rate of serious arrhythmias in patients with inferior MI and RV dysfunction. 68,69 In addition, RV dysfunction has been correlated with increased inducibility of VT at EPS. 70 Although there is no current evidence to support the role of early RV assessment to guide ICD implantation, these findings highlight the inadequacy of LVEF alone as a risk stratification tool for the prevention...

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Section: Electrophysiology Studymentioning

confidence: 99%

Section: Microvolt T-wave Alternansmentioning

confidence: 99%

Section: Variabilita Srdeční Frekvence a Zvýšení Klidové Srdeční Frekunclassified

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Sudden Cardiac Death Early After Myocardial Infarction

2014

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“…Various electric measures of arrhythmic risk, such as T-wave alternans, signal-averaged ECG, and electrophysiological study, have not demonstrated adequate or consistent discriminatory power. 4,5 Paradoxically, the mortality reduction benefit of primary prevention ICDs was established only when risk stratification was based on measures of left ventricular dysfunction and functional class (left ventricular ejection fraction Ͻ30% after myocardial infarction in MADIT II or left ventricular ejection fraction Ͻ35% with New York Heart Association class II to III in SCD-HeFT) rather than direct measures of arrhythmic risk.…”

Section: Article See P 835mentioning

confidence: 99%

Refining Patient Selection for Primary Prevention Implantable Cardioverter-Defibrillator Therapy

Tung

Swerdlow

2009

Circulation

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“…Initially, MTWA was considered an ideal method of noninvasively identifying those patients with reduced LV function (ejection fraction Ͻ30% to 35%) who would benefit from primary ICD implantation. However, two more recent prospective studies (MASTER and MTWA substudy SCD-HeFT) concluded that an abnormal MTWA result was not significantly associated with ICD-detected VTAs or able to independently predict VTA/mortality in patients with ischemic cardiomyopathy (27,28). Contrasting results from these heart failure studies suggest that MTWA may be useful for predicting VTAs if appropriate patient selection criteria are implemented.…”

Section: Discussionmentioning

confidence: 98%

Microvolt T-Wave Alternans in End-Stage Renal Disease Patients—Associations with Uremic Cardiomyopathy

Patel¹,

Mark²,

Halliday³

et al. 2011

Clinical Journal of the American Society of Nephrology

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SummaryBackground and objectives Premature cardiovascular (CV) events, especially sudden cardiac death, are common in ESRD patients and associated with uremic cardiomyopathy. Identification of high-risk patients is difficult. Microvolt T-wave alternans (MTWA) is a noninvasive method of detecting variability in electrocardiogram (ECG) T-wave morphology and is a promising technique for identifying patients at high risk of ventricular tachyarrhythmias. MTWA results of ESRD and hypertensive left ventricular hypertrophy (LVH) patients were assessed to determine the prevalence of abnormal results and associations with uremic cardiomyopathy.Design, setting, participants, & measurements In this single-center observational study, 200 ESRD and 30 LVH patients underwent assessment including CV history, ECG, cardiac magnetic resonance imaging, and an MTWA exercise test. MTWA results were classified as "negative" or "abnormal" on the basis of previously published reports.Results An abnormal MTWA result was more common in ESRD compared with LVH patients (57.5% versus 26.7%, respectively; P ϭ 0.002). In ESRD patients, MTWA was significantly associated with uremic cardiomyopathy, clinical history of atherosclerosis (coronary, cerebral, peripheral) and diabetes mellitus, older age, and hemodialysis therapy. Independent associations with an abnormal MTWA result were older age, macrovascular disease, increased left ventricle (LV) mass, and LV dilation. ConclusionsFeatures of uremic cardiomyopathy are associated with an abnormal MTWA result.

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

Abstract: 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).

Cited by 179 publications

References 30 publications

Sudden Cardiac Death Early After Myocardial Infarction

Sudden Cardiac Death Early After Myocardial Infarction

Refining Patient Selection for Primary Prevention Implantable Cardioverter-Defibrillator Therapy

Microvolt T-Wave Alternans in End-Stage Renal Disease Patients—Associations with Uremic Cardiomyopathy

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