on September 27, 2004
Published online before print September 27, 2004, doi: 10.1161/01.CIR.0000143160.14610.53
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Submitted on March 30, 2004
From the Department of Medicine, Columbia University, New York, NY (D.M.B., R.C.S., P.B.N., M.P., J.T.B.); New York Heart Center, Syracuse (J.D.); MetroHealth, Case Western Reserve University, Cleveland, Ohio (E.S.K.); Michigan Heart PC, Ypsilanti (T.S.); University of Florida, Gainesville (A.C.); Drexel University College of Medicine, Philadelphia, Pa (J.F.); New York University, New York (D.H.); University of Pennsylvania, Philadelphia (A.R.); and Minneapolis Heart Institute Foundation, Minneapolis (C.T.). * To whom correspondence should be addressed. E-mail: dmb9{at}columbia.edu.
Background--In 2003, the Centers for Medicaid and Medicare Services recommended QRS duration as a means to identify MADIT II-like patients suitable for implanted cardiac defibrillator (ICD) therapy. We compared the ability of microvolt T-wave alternans and QRS duration to identify groups at high and low risk of dying among heart failure patients who met MADIT II criteria for ICD prophylaxis. Methods and Results--Patients with MADIT II characteristics and sinus rhythm had a microvolt T-wave alternans exercise test and a 12-lead ECG. Our primary end point was 2-year all-cause mortality. Of 177 MADIT II-like patients, 32% had a QRS duration >120 ms, and 68% had an abnormal (positive or indeterminate) microvolt T-wave alternans test. During an average follow-up of 20±6 months, 20 patients died. We compared patients with an abnormal microvolt T-wave alternans test to those with a normal (negative) test, and patients with a QRS >120 ms with those with a QRS Conclusion--Among MADIT II-like patients, a microvolt T-wave alternans test is better than QRS duration at identifying a high-risk group and also better at identifying a low-risk group unlikely to benefit from ICD therapy.
Revised on June 30, 2004
Accepted on July 7, 2004
Microvolt T-Wave Alternans Distinguishes Between Patients Likely and Patients Not Likely to Benefit From Implanted Cardiac Defibrillator Therapy. A Solution to the Multicenter Automatic Defibrillator Implantation Trial (MADIT) II Conundrum
Daniel M. Bloomfield MD*,
120 ms; the hazard ratios for 2-year mortality were 4.8 (P=0.020) and 1.5 (P=0.367), respectively. The actuarial mortality rate was substantially lower among patients with a normal microvolt T-wave alternans test (3.8%; 95% confidence interval: 0, 9.0) than the mortality rate in patients with a narrow QRS (12.0%; 95% confidence interval: 5.6, 18.5). The corresponding false-negative rates are 3.5% and 10.2%, respectively.
Key words: heart failure • coronary disease • death, sudden • heart arrest • defibrillation
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