Ambulatory ECG-based T-wave alternans monitoring for risk assessment and guiding medical therapy: mechanisms and clinical applications.
Identification of individuals at risk for sudden cardiac death (SCD), the main cause of adult mortality in developed countries, remains a major challenge. The main contemporary noninvasive marker, left ventricular ejection fraction (LVEF), has not proved adequately reliable, as the majority of individuals who die suddenly have relatively preserved cardiac mechanical function. Monitoring of T-wave alternans (TWA), a beat-to-beat fluctuation in ST-segment or T-wave morphology, on ambulatory electrocardiogram (AECG) is an attractive approach on both scientific and clinical grounds. Specifically, TWA's capacity to assess risk for malignant arrhythmias has been shown to rest on sound electrophysiologic principles and AECG-based TWA monitoring can be performed in the flow of routine clinical evaluation. This review addresses: (1) electrophysiologic and ionic mechanisms underlying TWA's predictivity, (2) principles and practical aspects of AECG-based TWA monitoring, (3) clinical evidence supporting this approach to SCD risk stratification, and (4) current and potential applications in guiding medical therapy.
Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA. Electronic address: rverrier@bidmc.harvard.edu.
Richard L
RL
Verrier
Takanori
T
Ikeda
D000200:Action Potentials; D001145:Arrhythmias, Cardiac / Q000503:physiopathology; D001341:Autonomic Nervous System / Q000503:physiopathology; D003327:Coronary Disease / Q000503:physiopathology*; D016757:Death, Sudden, Cardiac / Q000453:epidemiology* / Q000517:prevention & control; D015716:Electrocardiography, Ambulatory; D006333:Heart Failure / Q000503:physiopathology; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D009203:Myocardial Infarction / Q000503:physiopathology; D017202:Myocardial Ischemia / Q000503:physiopathology; D018570:Risk Assessment; D018487:Ventricular Dysfunction, Left / Q000503:physiopathology; D014693:Ventricular Fibrillation / Q000503:physiopathology
AECG; APD; ATRAMI; AUC; Arrhythmia; Autonomic Tone and Reflexes After Myocardial Infarction; CHS; Cardiovascular Health Study; Cardiovascular mortality; ECG; EPHESUS; ESVEM; Electrophysiologic Study versus Electrocardiographic Monitoring; Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study; FINCAVAS; FINnish CArdioVAscular Study; HRT; Heterogeneity of repolarization; ICD; LVEF; MMA; NSTEACS; NSVT; PCI; Post-MI; REFINE; Risk Estimation Following Infarction Noninvasive Evaluation; Risk stratification; SCD; ST-elevation myocardial infarction; STEMI; Sudden cardiac death; T-wave alternans; TWA; VT; action potential duration; ambulatory electrocardiogram; area under the receiver operator characteristic curve; electrocardiogram/electrocardiographic; heart rate turbulence; implantable cardioverter defibrillator; left ventricular ejection fraction; modified moving average; non-ST-elevation acute coronary syndrome; nonsustained ventricular tachycardia; percutaneous coronary intervention; post-myocardial infarction; sudden cardiac death; ventricular tachycardia