Microvolt t-wave alternans during exercise and pacing are not comparable

Aims: The absence of microvolt T-wave alternans (MTWA) identifies a group of patients who are at low risk for ventricular arrhythmia or sudden cardiac death. However, in exercised assessed MTWA, 20–40% of all test results are indeterminate. We hypothesised that MTWA during pacing would yield less indeterminate results.

Methods and results: Thirty patients with ischaemic cardiomyopathy and prior dual chamber implantable cardioverter defibrillator implantation were enrolled. All patients underwent sequential MTWA testing using an exercise (E), atrial-paced (A), and atrioventricular-paced (AV) protocol. The number of indeterminate tests was lower during pacing (A: 17%; AV: 3%) compared with exercise (37%) (E vs. A: P = 0.015, E vs. AV: P = <0.001). When positive and indeterminate test results were grouped as non-negative, the concordance rates between E and A, E and AV, and A and AV were 60% (κ = 0.17), 57% (κ = 0.058), and 70% (κ = 0.348), respectively. If indeterminate results were excluded, agreements were 60% (κ = 0.19), 50% (κ = 0.129) and 67% (κ = 0.33), respectively.

Conclusion: Indeterminate test results are less common during pacing. However, there is a low concordance rate between test results using different protocols. This necessitates further study to determine the predictive value of each method in high risk patients with ischaemic cardiomyopathy.