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Intracardiac Electrogram T-Wave Alternans/Variability Increases Before Spontaneous Ventricular Tachyarrhythmias in Implantable Cardioverter-Defibrillator Patients: A Prospective, Multi-Center Study

Background— T-wave alternans (TWA) increases before ventricular tachycardia (VT) or fibrillation (VF), suggesting that it may warn of VT/VF in implantable cardioverter-defibrillator patients. Recently, we described a method for measuring alternans and nonalternans variability (TWA/V) from electrograms (EGMs) stored in implantable cardioverter-defibrillators before VT/VF. The goal of this prospective, multicenter study was to determine whether EGM TWA/V was greater before VT/VF than at baseline. Methods and Results— We enrolled 63 implantable cardioverter-defibrillator patients. TWA/V was computed from stored EGMs before spontaneous VT/VF and from sequential windows of 8 pairs of beats using 4 different control recordings: baseline rhythm, rapid pacing at 105 bpm, segments of ambulatory Holter EGMs matched to the time of VT/VF episodes, and EGMs before spontaneous supraventricular tachycardia. During follow-up, 28 patients had 166 episodes of VT/VF. TWA/V was greater before VT/VF (62.9±3.1 &mgr;V; n=28) than during baseline rhythm (12.8±1.8 &mgr;V; P<0.0001; n=62), during rapid pacing (14.5±2.0 &mgr;V; P<0.0001; n=52), before supraventricular tachycardia (27.5±6.1 &mgr;V; P<0.0001; n=9), or during time-matched ambulatory controls (12.3±3.5 &mgr;V; P<0.0001; n=16). By logistic regression, the odds of VT/VF increased by a factor of 2.2 for each 10-&mgr;V increment in TWA/V (P<0.0001). Conclusions— In implantable cardioverter-defibrillator patients, EGM TWA/V is greater before spontaneous VT/VF than in control recordings. Future implantable cardioverter-defibrillators that measure EGM TWA/V continuously may warn patients and initiate pacing therapies to prevent VT/VF.