title: Predictive value of microvolt T-wave alternans in patients with left ventricular dysfunction.
abstract: OBJECTIVE
  The purpose of this study was to prospectively evaluate the utility of microvolt T-wave alternans (TWA) in predicting arrhythmia-free survival and total mortality in patients with left ventricular (LV) dysfunction.
  
  
  BACKGROUND
  Microvolt TWA has been proposed as a useful tool in identifying patients unlikely to benefit from prophylaxis with implantable cardioverter-defibrillator (ICD) prophylaxis.
  
  
  METHODS
  We evaluated 286 patients with an LV ejection fraction </=35% who underwent TWA and electrophysiologic testing (EPS) owing to nonsustained ventricular tachycardia and/or syncope. Positive and indeterminate TWA results were grouped as non-negative. The primary end point was arrhythmia-free survival; the secondary end point was all-cause mortality.
  
  
  RESULTS
  Patients were followed for a mean of 38 +/- 11 months. There was no significant difference between the TWA-negative (n = 90; 31%) and non-negative (n = 196; 69%) groups with respect to ICD implant rates (54% vs. 64%, respectively; p = 0.95) or etiology of cardiomyopathy (ischemic: 73% vs. 76%; p = 0.71). The Kaplan-Meier curves demonstrated improved arrhythmia-free survival in TWA-negative patients (81% vs. 66% at 2 years; p < 0.001), including in both ischemic (79% vs. 64% at 2 years; p = 0.004) and nonischemic (88% vs. 71% at 2 years; p = 0.015) subgroups. Total mortality was lower in the TWA-negative group (10% vs. 18% at 2 years; p = 0.04). The negative predictive value of TWA for (2-year) total mortality was 90%, and 83% for EPS.
  
  
  CONCLUSIONS
  Microvolt TWA predicts arrhythmia-free survival among patients with LV dysfunction. However, the event rate in the TWA-negative group suggests that TWA may not be capable of identifying a sufficiently low-risk subset in this population to obviate the need for ICD implantation.
authors.affiliation: Department of Medicine, Division of Cardiology, Cornell University Medical Center, New York, New York 10021, USA.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Cantillon
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Stein
authors.forename: Steven M
authors.initials: SM
authors.lastname: Markowitz
authors.forename: Suneet
authors.initials: S
authors.lastname: Mittal
authors.forename: Bindi K
authors.initials: BK
authors.lastname: Shah
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Morin
authors.forename: Eran S
authors.initials: ES
authors.lastname: Zacks
authors.forename: Matthew
authors.initials: M
authors.lastname: Janik
authors.forename: Shaun
authors.initials: S
authors.lastname: Ageno
authors.forename: Andreas C
authors.initials: AC
authors.lastname: Mauer
authors.forename: Bruce B
authors.initials: BB
authors.lastname: Lerman
authors.forename: Sei
authors.initials: S
authors.lastname: Iwai
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D001145:Arrhythmias, Cardiac / Q000175:diagnosis*; D016757:Death, Sudden, Cardiac; D018572:Disease-Free Survival; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000150:complications; D019370:Observation; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D013318:Stroke Volume; D018487:Ventricular Dysfunction, Left / Q000150:complications* / Q000503:physiopathology