Alpha 2.0
Login Register
» Articles » PMID: 38804218

Lack of Prognostic Value of T-Wave Alternans for Implantable Cardioverter-Defibrillator Benefit in Primary Prevention

Overview
Journal J Am Heart Assoc
Specialty Cardiology & Vascular Diseases
Date 2024 May 28
PMID 38804218
Authors
Ari Pelli
Tuomas V Kentta
M Juhani Junttila
Cynthia Huber
Simon Schlogl
Markus Zabel
Marek Malik
Rik Willems
Marc A Vos
Markus Harden
Tim Friede
Christian Sticherling
Heikki V Huikuri
Affiliations
Soon will be listed here.
Abstract

Background: New methods to identify patients who benefit from a primary prophylactic implantable cardioverter-defibrillator (ICD) are needed. T-wave alternans (TWA) has been shown to associate with arrhythmogenesis of the heart and sudden cardiac death. We hypothesized that TWA might be associated with benefit from ICD implantation in primary prevention.

Methods And Results: In the EU-CERT-ICD (European Comparative Effectiveness Research to Assess the Use of Primary Prophylactic Implantable Cardioverter-Defibrillators) study, we prospectively enrolled 2327 candidates for primary prophylactic ICD. A 24-hour Holter monitor reading was taken from all recruited patients at enrollment. TWA was assessed from Holter monitoring using the modified moving average method. Study outcomes were all-cause death, appropriate shock, and survival benefit. TWA was assessed both as a contiguous variable and as a dichotomized variable with cutoff points <47 μV and <60 μV. The final cohort included 1734 valid T-wave alternans samples, 1211 patients with ICD, and 523 control patients with conservative treatment, with a mean follow-up time of 2.3 years. TWA ≥60 μV was a predicter for a higher all-cause death in patients with an ICD on the basis of a univariate Cox regression model (hazard ratio, 1.484 [95% CI, 1.024-2.151]; =0.0374; concordance statistic, 0.51). In multivariable models, TWA was not prognostic of death or appropriate shocks in patients with an ICD. In addition, TWA was not prognostic of death in control patients. In a propensity score-adjusted Cox regression model, TWA was not a predictor of ICD benefit.

Conclusions: T-wave alternans is poorly prognostic in patients with a primary prophylactic ICD. Although it may be prognostic of life-threatening arrhythmias and sudden cardiac death in several patient populations, it does not seem to be useful in assessing benefit from ICD therapy in primary prevention among patients with an ejection fraction of ≤35%.

References
1.
Seegers J, Bergau L, Tichelbacker T, Malik M, Zabel M . ICD risk stratification studies - EU-CERT-ICD and the European perspective. J Electrocardiol. 2016; 49(6):831-836. DOI: 10.1016/j.jelectrocard.2016.08.011. View
2.
Sabbag A, Suleiman M, Laish-Farkash A, Samania N, Kazatsker M, Goldenberg I . Contemporary rates of appropriate shock therapy in patients who receive implantable device therapy in a real-world setting: From the Israeli ICD Registry. Heart Rhythm. 2015; 12(12):2426-33. DOI: 10.1016/j.hrthm.2015.08.020. View
3.
Bergau L, Willems R, Sprenkeler D, Fischer T, Flevari P, Hasenfuss G . Differential multivariable risk prediction of appropriate shock versus competing mortality - A prospective cohort study to estimate benefits from ICD therapy. Int J Cardiol. 2018; 272:102-107. DOI: 10.1016/j.ijcard.2018.06.103. View
4.
Dagres N, Hindricks G . Devices for management of sudden cardiac death: Successes, challenges and perspectives. Int J Cardiol. 2017; 237:34-37. DOI: 10.1016/j.ijcard.2017.03.053. View
5.
Nieminen T, Lehtimaki T, Viik J, Lehtinen R, Nikus K, Koobi T . T-wave alternans predicts mortality in a population undergoing a clinically indicated exercise test. Eur Heart J. 2007; 28(19):2332-7. DOI: 10.1093/eurheartj/ehm271. View