Key result
Noninvasive MTWA testing matches invasive EPS with ~95% negative predictive value for sudden death.
Why the study?
Risk stratification with LVEF alone is inefficient, and while EPS improves efficiency, it is invasive. The authors sought to determine whether noninvasive MTWA testing could identify patients who benefit from ICDs as well as EPS.
Does noninvasive microvolt T-wave alternans (MTWA) testing identify patients who benefit from implantable cardioverter-defibrillators (ICDs) as well as invasive electrophysiological study (EPS) in patients with ischemic cardiomyopathy and nonsustained ventricular tachycardia?
Does noninvasive microvolt T-wave alternans (MTWA) testing identify patients who benefit from implantable cardioverter-defibrillators (ICDs) as well as invasive electrophysiological study (EPS) in patients with ischemic cardiomyopathy and nonsustained ventricular tachycardia?
Absolute Event Rate: 9% vs 11%
Noninvasive MTWA testing provides comparable 1-year predictive value to invasive EPS for identifying patients with ischemic cardiomyopathy who benefit from prophylactic ICD insertion.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Where it is going to be of value—and why the academic electrophysiologists are waiting for more clinical data—is to see if it has more compelling positive predictive value in patients in the intermediate-risk group.”
“you clearly would want that patient to have a defibrillator—you don't need any other tests”
MTWA may stratify sudden death risk comparably to EPS in ischemic cardiomyopathy; leaves open whether combined testing improves ICD selection.
OBJECTIVES: Because risk stratification with electrophysiological study (EPS) improves efficiency but is invasive, we sought to determine whether noninvasive microvolt T-wave alternans (MTWA) testing could identify patients who benefit from implantable cardioverter-defibrillators (ICDs) as well as EPS. BACKGROUND: Prevention of sudden cardiac death on the basis of left ventricular ejection fraction (LVEF) alone is inefficient, because most ICDs never deliver therapy. METHODS: The ABCD (Alternans Before Cardioverter Defibrillator) trial is a multicenter prospective study that enrolled patients with ischemic cardiomyopathy (LVEF < or =0.40) and nonsustained ventricular tachycardia. All patients underwent MTWA and EPS. ICDs were mandated if either test was positive. RESULTS: Of 566 patients followed for a median of 1.9 years, 39 (7.5%) met the primary end point of appropriate ICD discharge or sudden death at 1 year. As hypothesized, primary analysis showed that MTWA achieved 1-year positive (9%) and negative (95%) predictive values that were comparable to EPS (11% and 95%, respectively). In addition, secondary analysis showed that at the pre-specified 1-year end point, event rates were significantly higher in patients with both a positive MTWA-directed strategy (hazard ratio: 2.1, p = 0.03) and a positive EPS-directed strategy (hazard ratio: 2.4, p = 0.007). Moreover, the event rate in patients with both negative MTWA test and EPS was lower than in those with 2 positive tests (2% vs. 12%; p = 0.017). CONCLUSIONS: The ABCD study is the first trial to use MTWA to guide prophylactic ICD insertion. Risk stratification strategies using noninvasive MTWA versus invasive EPS are comparable at 1 year and complementary when applied in combination. Strategies employing MTWA, EPS, or both might identify subsets of patients least likely to benefit from ICD insertion. (Study to Compare TWA Test and EPS Test for Predicting Patients at Risk for Life-Threatening Heart Rhythms [ABCD Study]; NCT00187291).
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Costantini et al. (2009) studied Ischemic cardiomyopathy and nonsustained ventricular tachycardia (n=566). Microvolt T-wave alternans (MTWA) testing vs. Electrophysiological study (EPS) was evaluated on Appropriate ICD discharge or sudden death at 1 year. Noninvasive microvolt T-wave alternans testing yielded 1-year positive (9%) and negative (95%) predictive values for ICD discharge or sudden death comparable to invasive EPS (11% and 95%).
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