Arrhythmia/Electrophysiology 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 cardioverterdefibrillators 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 V; n 28) than during baseline rhythm (12.8 1.8 V; P 0.0001; n 62), during rapid pacing (14.5 2.0 V; P 0.0001; n 52), before supraventricular tachycardia (27.5 6.1 V; P 0.0001; n 9), or during time-matched ambulatory controls (12.3 3.5 V; P 0.0001; n 16). By logistic regression, the odds of VT/VF increased by a factor of 2.2 for each 10V 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. (Circulation. 2011;123:1052-1060.)