The clinical value of T-wave alternans derived from Holter monitoring

Microvolt-level T-wave alternans (TWA) assessed by spectral method during an exercise stress test has been widely studied for risk stratification. Several studies have documented the association of a positive TWA with total mortality and arrhythmic events. Nevertheless, the need to achieve an elevated and stabilized heart rate resulting in a considerable proportion of indeterminate test results constitutes one of the main limitations of this method. It is well recognized that arrhythmic events may be triggered not only by physical but also by mental stress and are not necessarily associated with exercise. Detection of TWA in ambulatory electrocardiogram recordings during daily activities might be a valuable option in risk stratification. This review describes the modified moving average (MMA) technique for detection of TWA and summarizes the results of clinical studies on the prognostic value of MMA-TWA. So far, MMA-TWA has been studied in over 5000 patients including those evaluated during exercise as well as during daily activities with ambulatory ECG recordings. The results of these studies indicate that increased MMA-TWA is associated with higher risk of cardiac mortality and arrhythmic events.