Circulation. 2004;110:1885-1889
Published online before print September 27, 2004, doi: 10.1161/01.CIR.0000143160.14610.53
Published online before print September 27, 2004, doi: 10.1161/01.CIR.0000143160.14610.53
(Circulation. 2004;110:1885-1889.)
© 2004 American Heart Association, Inc.
Arrhythmia/Electrophysiology |
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
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.).
Correspondence to Daniel M. Bloomfield, MD, Data Coordinating Center, The MTWA in CHF Study, PH 9-103D, Columbia University, 630 W 168th St, New York, NY 10032. E-mail dmb9{at}columbia.edu
Received March 30, 2004; revision received June 30, 2004; accepted July 7, 2004.
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 
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.
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.
Key Words: heart failure • coronary disease • death, sudden • heart arrest • defibrillation
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