Prognostic Significance of T Wave Alternans

The Prevalence and Prognostic Significance of T Wave Alternans in Patients With Severe Congestive Heart Failture

To evaluate whether T Wave Alternans can predict ventricular arrhythmias and sudden cardiac death (SCD) in a prospective epidemiologic natural history study.

The prospective epidemiologic pilot study included 550 patients that had left ventricular dysfunction and no history of sustained ventricular arrhythmias. The primary hypothesis tested was whether there was an increased risk of having an arrhythmic event when T Wave Alternans was present in the patient. The secondary aims included comparing risk due to T Wave Alternans between the ischemic patients and non-ischemic patients and assessing whether T Wave Alternans remained an independent predictor of risk upon adjustment for other known risk factors for arrhythmic events such as ejection fraction, ventricular ectopy, NSVT, average NN interval, and RR interval variability.

The study approach was a standard epidemiologic surveillance technique. The subject population consisted of individuals with Class I to III heart failure who will underwent a TWA and Holter monitor test and then were followed for up to two years or until arrhythmic events occured.

Study Overview

• Status: Completed
• Conditions: Heart Diseases; Ventricular Fibrillation; Heart Arrest; Death, Sudden, Cardiac; Ventricular Arrhythmia
• Intervention / Treatment: Procedure: ECG

Detailed Description

Sudden cardiac death accounts for approximately 400,000 deaths each year in the United States and remains a health problem of epidemic proportions. Most sudden cardiac deaths are caused by fatal ventricular arrhythmias. An effort aimed at the primary prevention of sudden cardiac death requires efficient identification of patients who are at high enough risk for having these arrhythmias to warrant aggressive prophylactic therapy. A number of recently completed, randomized clinical trials have demonstrated that an implantable cardiac defibrillator (ICD) can prevent sudden cardiac death in a highly selected group of high-risk patients. When these trials are viewed together, the only patients in whom the prophylactic implantation of an ICD has proven benefit are those patients identified by documented, spontaneous or inducible, sustained ventricular arrhythmias.

Two randomized treatment trials (MADIT II, SCD-HEFT) tested the hypothesis that implantation of an ICD would reduce mortality in patients with congestive heart failure (CHF) and left ventricular dysfunction without any further risk tratification. However, the implications of these two trials-implantation of an ICD in every patient with CHF-were unlikely to be accepted either by the medical community or by health care payers. More efficient methods of risk stratification were necessary to identify those patients with CHF who were most likely to benefit from prophylactic treatment with an ICD.

T Wave Alternans is a subtle every-other-beat variation in electrocardiographic T waves that is prognostic of patients at high risk for life-threatening cardiac arrhythmias and sudden cardiac death. It has recently been shown that T Wave Alternans (TWA) measured during exercise is strongly associated with inducible monomorphic CVT and with subsequent spontaneous arrhythmic events. This preliminary data suggest that TWA may be an efficient and non-invasive surrogate for electrophysiologic testing to screen patients who may be at high-risk for sudden cardiac death.

• Study Type: Observational
• Enrollment (Actual): 549

Contacts and Locations

Study Locations

• United States
  • New York
    • New York, New York, United States, 10023
      • Columbia University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Patients with left ventricular dusfunction or non-ischemic cardiomyopathy, and are at high risk for sudden cardiac death.

Description

Inclusion Criteria

1. Patients with left ventricular dusfunction
2. Patients with non-ischemic cardiomyopathy

Exclusion Criteria

1. Patients not at high risk for sudden cardiac death (SCD)

Study Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
ECG recording; After the tests are completed, people who enroll in this study are followed by telephone, 1, 4, 8, 12 16, 20 and 24 months. During these follow-up telephone calls a research coordinator asks about the participant's health condition and about cardiovascular medications that are being taken.	Procedure: ECG; A diagnostic tool that is routinely used to assess the electrical and muscular functions of the heart (non-experimental).; Other Names: Electrocardiogram

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Pevalence of SCD with earlier testing that indicated TWA	Up to 24 months

Collaborators and Investigators

• Sponsor: Columbia University
• Collaborators: National Heart, Lung, and Blood Institute (NHLBI)
• Investigators: Principal Investigator: John Bigger, Professor Emeritus of Medicine and Pharmacology, Columbia University; Principal Investigator: John Bigger, Columbia University

Publications and helpful links

General Publications

• Bloomfield DM, Bigger JT, Steinman RC, Namerow PB, Parides MK, Curtis AB, Kaufman ES, Davidenko JM, Shinn TS, Fontaine JM. Microvolt T-wave alternans and the risk of death or sustained ventricular arrhythmias in patients with left ventricular dysfunction. J Am Coll Cardiol. 2006 Jan 17;47(2):456-63. doi: 10.1016/j.jacc.2005.11.026. Epub 2005 Dec 15.

Study record dates

Study Major Dates

• Study Start: January 1, 2003
• Primary Completion (Actual): December 1, 2009
• Study Completion (Actual): February 1, 2012

Study Registration Dates

• First Submitted: November 16, 2000
• First Submitted That Met QC Criteria: November 16, 2000
• First Posted (Estimate): November 17, 2000

Study Record Updates

• Last Update Posted (Estimate): December 23, 2015
• Last Update Submitted That Met QC Criteria: December 21, 2015
• Last Verified: December 1, 2015

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Pathologic Processes; Cardiovascular Diseases; Arrhythmias, Cardiac; Death; Heart Diseases; Heart Arrest; Ventricular Fibrillation; Death, Sudden, Cardiac; Death, Sudden
• Other Study ID Numbers: AAAB1399; R01HL064862 (U.S. NIH Grant/Contract)