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

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 less than or equal to 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.