T-wave alternans in risk stratification of patients with nonischemic dilated cardiomyopathy: Can it help to better select candidates for ICD implantation?

Gaetano M. De Ferrari, Antonio Sanzo

Research output: Contribution to journalArticle

Abstract

Background: Prophylactic implantable cardioverter-defibrillator (ICD) therapy reduces mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF), but the absolute risk reduction is relatively small. Thus, there is a strong need to identify reliable risk stratifiers, particularly among patients with nonischemic cardiomyopathy (NIDCM), in whom the search for risk predictors has been particularly frustrating. Objective: This study sought to review data regarding T-wave alternans (TWA) in patients with NIDCM and to discuss its potential role. Methods: We included in a meta-analysis clinical trials that enrolled ≥50 NICDM patients, had a follow-up of ≥1 year, and provided detailed data on NIDCM patients, in case of mixed population. Relative risks were derived from absolute numbers of events in abnormal (positive + indeterminate test whenever possible) TWA versus normal (negative) TWA group. Results: Eight studies with 1,456 patients (mean age 56 years, LVEF 30%, follow-up 25 months) were included. A negative TWA test occurred in 33%, and was indeterminate in 21% of the patients. The primary end point (VT+VF+sudden or all-cause death) occurred in 14.7% abnormal versus 3.8% normal TWA patients. The relative risk for the cumulative data was found to be 2.99 (95% confidence interval: 1.88 to 4.75). The negative predictive value was 96.2%. Conclusion: A normal TWA test identifies one-third of NIDCM patients who have a very good prognosis and are unlikely to significantly benefit from ICD therapy. A randomized clinical trial evaluating the utility of TWA in guiding therapy seems warranted, possibly a noninferiority trial of medical therapy only versus ICD in TWA-negative patients.

Original languageEnglish
JournalHeart Rhythm
Volume6
Issue number3 SUPPL.
DOIs
Publication statusPublished - Mar 2009

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Implantable Defibrillators
Dilated Cardiomyopathy
Stroke Volume
Numbers Needed To Treat
Therapeutics
Cardiomyopathies
Meta-Analysis
Cause of Death
Randomized Controlled Trials
Heart Failure
Clinical Trials
Confidence Intervals
Mortality

Keywords

  • Heart failure
  • Nonischemic cardiomyopathy
  • Risk stratification
  • Sudden death
  • T-wave alternans

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

@article{1f3f57d77aac4f79b189209297acc0e3,
title = "T-wave alternans in risk stratification of patients with nonischemic dilated cardiomyopathy: Can it help to better select candidates for ICD implantation?",
abstract = "Background: Prophylactic implantable cardioverter-defibrillator (ICD) therapy reduces mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF), but the absolute risk reduction is relatively small. Thus, there is a strong need to identify reliable risk stratifiers, particularly among patients with nonischemic cardiomyopathy (NIDCM), in whom the search for risk predictors has been particularly frustrating. Objective: This study sought to review data regarding T-wave alternans (TWA) in patients with NIDCM and to discuss its potential role. Methods: We included in a meta-analysis clinical trials that enrolled ≥50 NICDM patients, had a follow-up of ≥1 year, and provided detailed data on NIDCM patients, in case of mixed population. Relative risks were derived from absolute numbers of events in abnormal (positive + indeterminate test whenever possible) TWA versus normal (negative) TWA group. Results: Eight studies with 1,456 patients (mean age 56 years, LVEF 30{\%}, follow-up 25 months) were included. A negative TWA test occurred in 33{\%}, and was indeterminate in 21{\%} of the patients. The primary end point (VT+VF+sudden or all-cause death) occurred in 14.7{\%} abnormal versus 3.8{\%} normal TWA patients. The relative risk for the cumulative data was found to be 2.99 (95{\%} confidence interval: 1.88 to 4.75). The negative predictive value was 96.2{\%}. Conclusion: A normal TWA test identifies one-third of NIDCM patients who have a very good prognosis and are unlikely to significantly benefit from ICD therapy. A randomized clinical trial evaluating the utility of TWA in guiding therapy seems warranted, possibly a noninferiority trial of medical therapy only versus ICD in TWA-negative patients.",
keywords = "Heart failure, Nonischemic cardiomyopathy, Risk stratification, Sudden death, T-wave alternans",
author = "{De Ferrari}, {Gaetano M.} and Antonio Sanzo",
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T1 - T-wave alternans in risk stratification of patients with nonischemic dilated cardiomyopathy

T2 - Can it help to better select candidates for ICD implantation?

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AU - Sanzo, Antonio

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N2 - Background: Prophylactic implantable cardioverter-defibrillator (ICD) therapy reduces mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF), but the absolute risk reduction is relatively small. Thus, there is a strong need to identify reliable risk stratifiers, particularly among patients with nonischemic cardiomyopathy (NIDCM), in whom the search for risk predictors has been particularly frustrating. Objective: This study sought to review data regarding T-wave alternans (TWA) in patients with NIDCM and to discuss its potential role. Methods: We included in a meta-analysis clinical trials that enrolled ≥50 NICDM patients, had a follow-up of ≥1 year, and provided detailed data on NIDCM patients, in case of mixed population. Relative risks were derived from absolute numbers of events in abnormal (positive + indeterminate test whenever possible) TWA versus normal (negative) TWA group. Results: Eight studies with 1,456 patients (mean age 56 years, LVEF 30%, follow-up 25 months) were included. A negative TWA test occurred in 33%, and was indeterminate in 21% of the patients. The primary end point (VT+VF+sudden or all-cause death) occurred in 14.7% abnormal versus 3.8% normal TWA patients. The relative risk for the cumulative data was found to be 2.99 (95% confidence interval: 1.88 to 4.75). The negative predictive value was 96.2%. Conclusion: A normal TWA test identifies one-third of NIDCM patients who have a very good prognosis and are unlikely to significantly benefit from ICD therapy. A randomized clinical trial evaluating the utility of TWA in guiding therapy seems warranted, possibly a noninferiority trial of medical therapy only versus ICD in TWA-negative patients.

AB - Background: Prophylactic implantable cardioverter-defibrillator (ICD) therapy reduces mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF), but the absolute risk reduction is relatively small. Thus, there is a strong need to identify reliable risk stratifiers, particularly among patients with nonischemic cardiomyopathy (NIDCM), in whom the search for risk predictors has been particularly frustrating. Objective: This study sought to review data regarding T-wave alternans (TWA) in patients with NIDCM and to discuss its potential role. Methods: We included in a meta-analysis clinical trials that enrolled ≥50 NICDM patients, had a follow-up of ≥1 year, and provided detailed data on NIDCM patients, in case of mixed population. Relative risks were derived from absolute numbers of events in abnormal (positive + indeterminate test whenever possible) TWA versus normal (negative) TWA group. Results: Eight studies with 1,456 patients (mean age 56 years, LVEF 30%, follow-up 25 months) were included. A negative TWA test occurred in 33%, and was indeterminate in 21% of the patients. The primary end point (VT+VF+sudden or all-cause death) occurred in 14.7% abnormal versus 3.8% normal TWA patients. The relative risk for the cumulative data was found to be 2.99 (95% confidence interval: 1.88 to 4.75). The negative predictive value was 96.2%. Conclusion: A normal TWA test identifies one-third of NIDCM patients who have a very good prognosis and are unlikely to significantly benefit from ICD therapy. A randomized clinical trial evaluating the utility of TWA in guiding therapy seems warranted, possibly a noninferiority trial of medical therapy only versus ICD in TWA-negative patients.

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KW - Sudden death

KW - T-wave alternans

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