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MicroVolt T Wave Alternans (MTWA-Spectral Method) Risk Assessment of Malignant Arrhythmias (introduction)

Class IIa (level of Evidence A)  in AHA/ACC/ESC Guidelines

European News Web Page

Editor: D. Marangoni  Updated September 14, 2021



Marangoni Ravasi Interview on Science

D.Marangoni Book

ESC Congress 2016 in Review article:  Prophylactic use of ICD in patients with non ischemic heart failure: results from the DANISH study. FAILED

Results from the DANISH study [Køber L et al. N Engl J Med. 2016], failed to show a significant reduction in all-cause mortality with the prophylactic use of implantable cardioverter defibrillator (ICD) devices in patients with symptomatic systolic heart failure (HF) not caused by coronary artery disease.



Microvolt T-wave alternans profiles in patients with pulmonary arterial hypertension compared to patients with left ventricular systolic dysfunction and a group of healthy volunteers.


Improving the appropriateness of sudden arrhythmic death primary prevention by implantable cardioverter-defibrillator therapy in patients with low left ventricular ejection fraction. Point of view. Full Text J Cardiovasc Med (Hagerstown). 2016 Apr


Heart Rhythm J: Contemporary rates of appropriate shock therapy in patients who receive implantable device therapy in a real-world setting: From the Israeli ICD Registry: appropriate ICD shock therapy at 30-month follow-up was 2.6%.These findings suggest a need for improved risk stratification and patient selection in this population..


Remarks on polyparametric assessment of sudden death risk for primary prevention ICD implantation in patients with left ventricular dysfunction of ischemic and non ischemic etiology. Italian Association of Hospital Cardiologists (ANMCO) Experts Position Paper.


Usefulness of T-Wave Alternans to Distinguish Right Ventricular Cardiomyopathy From Idiopathic Right Ventricular Outflow Tract Tachycardia.


Usefulness of microvolt T-wave alternans testing in the assessment of all-cause mortality and life-threatening ventricular arrhythmia risk in patients with left ventricular dysfunction.



NEW MTWA Application to detect ischemia:

-T-Wave Alternans Is Linked to Microvascular Obstruction and to Recurrent Coronary Ischemia After Myocardial Infarction.

- The value of microvolt T-wave alternans in the diagnosis of reversible myocardial ischemia in patients without structural

cardiac disease (First Prize Dubrovnik Cardiology Highlights an ESC Update Programme)


 Prospective Use of Microvolt T-Wave Alternans Testing to Guide Primary Prevention Implantable Cardioverter

Defibrillator Therapy

Multicenter Study (650 patients with ICD implants based on MTWA results in patients with EF< and > 35%) full test free

Circulation Journal June 15 2015.


MTWA at ISHNE Congress in Lyon - France


Microvolt T-wave alternans in patients undergoing elective coronary artery bypass grafting: a pilot study


Remarks on the guideline recommendations for cardioverter-defibrillator implantation for primary prevention of sudden cardiac Death in patients with severe ventricular dysfunction. Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO)/Italian Society of Cardiology (SIC)/Italian Association of Arrhythmology and Cardiac Pacing (AIAC)


Medicare Final Decision

The Centers for Medicare & Medicaid Services has decided that no National Coverage Determination (NCD) is appropriate at this time for microvolt T-wave alternans (MTWA) testing using the modified moving average (MMA) method for the evaluation of patients at risk for sudden cardiac death (January 13, 2015)


Centers for Medicare and Medicaid Services -  National Coverage Analyses: Microvolt T-wave Alternans Posted proposed decision memo (October 23,2014):

MMA METHOD again NOT approved. Only Spectral Analytic Method is reimbursed



Time for a Change -- A New Approach to ICD Replacement


MTWA the best Sudden Death predictor method in Dilated Cardiomiopathy: Circ Arrhythm Electrophysiol. 2014 Sep 27

Multiple Autonomic and Repolarization Investigation of Sudden Cardiac Death in Dilated Cardiomyopathy and Controls.


TWA at ESC 2014


HRS 2014 abstract: “Reasons for Nonimplantation of Primary Prevention ICDs and Outcomes in a Population of Patients with Left Ventricular Ejection Fractions of 35% or Less” - Patients refusing ICD (8%) had a lower mortality than patients with ICD implanted. Editor comment: MTWA can help in the decision not to implant up to 40% of the ICD patients


FULL TEXT of Clinical use of microvolt T-wave alternans in patients with depressed left ventricular function eligible for ICD implantation: mortality outcomes after long term follow-up (International Journal of Cardiology Volume 168, Issue 3, 3 October 2013, Pages 30383040)


ADVANCES CARDIAC ELECTROPHYSIOLOGY Symposium - ROME Italy November 21/22  2013: Time: 9:00 Sala Mancini Dr Molon presentation of the published data on Clinical use of microvolt T-wave alternans in patients with depressed left ventricular function eligible for ICD implantation: mortality outcomes after long term follow-up


A combined anatomic and electrophysiologic substrate based approach for sudden cardiac death risk stratification.( Am Heart J. 2013 Oct)


The need to modify patient selection to improve the benefits of implantable cardioverter-defibrillator for primary prevention of sudden death in non-ischaemic dilated cardiomyopathy (Europace 2014 Aug. 14)


Powerpoint Presentation with comments of MTWA in ICD Decision Making on International Journal of Cardiology Web Page


M T W Alternans on “Exercise Standards for Testing and Training: A Scientific Statement From AHA”

 Circulation. 2013;128:873-934. NEW:  Extract with reference to Alternans



Clinical use of microvolt T-wave alternans in patients with depressed left ventricular function eligible for ICD implantation: mortality outcomes after long term follow-up
International Journal of Cardiology,
In Press, Corrected Proof, Available online 3 May 2013
Giulio Molon, Richard J. Cohen, Tiziana de Santo, Alessandro Costa, Enrico Barbieri

Editor Comments


HRS 2013: Disagreeing with an influential thought leader on ICD use and ICDs, goals of care, and end of life: Difficult conversations (Hyde Park talk at HRS 2013) (theHeart.org)



HRS 2013 MTWA useful and reliable in ICD Decision Making:


-        PO06-99 - Microvolt T-wave Alternans Testing And Risk Of Death In Patients With And Without ICDs Abstract


-        HRS 2013 MTWA in ICD Decision Making Poster


-        Editor Reminder: MTWA Test Accurately Predicts Risk of sudden Cardiac Arrest in patients who do not already have implantable cardiac defibrillators , Meta-Analysis Finds (Heart Rhythm 2009;6:S36 –S44)





ICD Decision making with MTWA: Negative result of microvolt T-wave alternans test is helpful in scheduling the order of cardioverter-defibrillator implantation in primary prevention of sudden cardiac death in individuals with the left ventricular systolic dysfunction (Oct 2012)


AHA 2012: Microvolt T-wave Alternans in Adults with the Chosen Forms of Congenital Heart


Microvolt T-wave alternans predicts cardiac events after acute myocardial infarction in patients treated with primary

percutaneous coronary intervention (Adv Med Sci 2012)


Another positive MTWA paper (Sensitivity 100%) with detail analysis of  indeterminate tests: the proportion of indeterminate MTWA results due to technical factors of no prognostic significance, was small (5%). Kardiologia Polska 2012; 70, 8: 795–802


 Sudden Cardiac Death and Implantable Cardioverter Defibrillators: from Europace 2012


Case Study: MTWA Identifies Latent Arrhythmic Risk in Hypertensive Cardiomyopathy


New HRS Statement :Ischemic Cardio­myopathy EF=36-40% Consider Further Risk Stratification


Microvolt T-wave alternans and other noninvasive predictors of serious arrhythmic events in patients with an implanted cardioverter-defibrillator.

Multivariate analysis including parameters that potentially affected the occurrence of major arrhythmic cardiac events

Sredniawa B, Kowalczyk J, Lenarczyk R, Kowalski O, Sędkowska A, Cebula S, Musialik Łydka A, Kalarus Z.

Kardiol Pol. 2012;70(5):447-455.



A Decisional Needs Assessment Related to Implantable Cardioverter-Defibrillators for the Primary Prevention of Sudden Cardiac Death (The Informed Medical Decisions Foundation): MTWA can help in Shared Decision Making

HRS 2012 Boston TWA Abstracts

Soccer star's cardiac arrest prompts screening questions…

Reminder: MTWA risk assessment  in Professional Athletes papers:

-       F. Furlanello et al. Microvolt T-Wave Alternans as Predictor of Electrophysiological Testing Results in Professional Competitive Athletes ANE 2004

-      G. Inama et al. Microvolt T-wave alternans for risk stratification in athletes with ventricular arrhythmias: correlation with programmed ventricular stimulation. ANE 2008

Latent microvolt T-wave alternans in survivors of unexplained cardiac arrest unmasked by epinephrine challenge.

 Heart Rhythm. 2012 Feb 25. [Epub ahead of print]

ACC 2012 New Meta Analysis :MTWA predictive also in ICD patients

New MTWA study published in the Heart Rhythm 2012 Journal: a pooled analysis of 2,883 patients, strong endorsement of MTWA testing in patients with a broad spectrum of ejection fractions.

NEW: MTWA Reimbursement in Japan

Role of Substrate and Triggers in the Genesis of Cardiac Alternans, From  the Myocyte to the Whole Heart: Implications for Therapy Faisal M. Merchant and Antonis A. Armoundas ( Circulation 2012;125 539-549)

Good opportunity to use  mTWA in Decision Making with the Informed Consent:

·       Patient and Cardiologist Perceptions on Decision Making for Implantable Cardioverter-defibrillators (PACE 2012) introduction

·       Don't routinely replace spent ICDs: Proposal (January, 2012 New England Journal of Medicine)

Very Important presentations at Venice Arrhythmias 2011:

·         Real world money saving with MTWA application (abstract)

·         No correlation between mtwa Spectral method and MMA TWA(abstract).

Predictive Value of Microvolt T-Wave Alternans for Cardiac Death or Ventricular Tachyarrhythmic Events in Ischemic and Nonischemic Cardiomyopathy Patients: A Meta-Analysis (on 5600 patients – ANE 2011)

T-wave Alternans Testing in Pacemaker Patients Comparison of Pacing Modes and Long-Term Prognostic Relevance (5 years follow up) - Pacing and Clinical Electrophysiology


PREVENT-SCD Published: The MTWA negative predictive value was 100% at one year, 98.6% at two years, and 97.0% at three years

The Use of MTWA in the Detection of Ischemia

MTWA Warns of Impending Cardiac Arrest (Diagnostic and Interventional Cardiology - Oct 11)

Implementation of ICD guidelines is difficult in European countries facing budget crunch

80% of SCD in Women Could Be Avoided With All-Around Healthy Lifestyle - JAMA 2011; 306:62-69

 ( ICDs are not always necessary but risk analysis is necessary)

Repolarization Alternans Reveals Vulnerability to Human Atrial Fibrillation (Circulation. 2011;123:2922-2930)

Implantable Defibrillators May Not Improve Survival for Older Patients (June 2nd in the American Journal of Cardiology).. select better your patients

"Rhetoric" mars and distorts primary-prevention ICD trial reports: Analysis (April 9, 2011 in American Journal of Cardiology)

TWA at HRS 2011 San Francisco

Relationship Between Early Diastolic Dysfunction and Abnormal Microvolt

T-Wave Alternans in Patients with Type 2 Diabetes (Circulation I. March 2011)

Toward More Optimal Use of Primary Prevention

Implantable Cardioverter-Defibrillators (extracted from Circulation C. March 2011)

TWA at ACC 2011 New Orleans

Irritable Contemporary Risk of Implantable Cardioverter Defibrillators (…select better your patients)

TWA inside ICD (Circulation February 28, 2011)

MTWA Web Seminar

Mechanisms Underlying the Lack of Effect of Implantable Cardioverter-Defibrillator Therapy on Mortality in High-Risk Patients With Recent Myocardial Infarction

Insights from the Defibrillation in Acute Myocardial Infarction Trial (DINAMIT)….. Select better your patients…..

AHA 2010 TWA presentations

Primary ICD implants may not benefit seniors

...That’s why a better stratification method is needed...

Ongoing Clinical Trials on MTWA

MTWA at 2010 European Congress of Cardiology

ESC important abstract on Pacing modes

Shocking revelations at the HRS…

(that’s why it is better to select the ICD patients)

MTWA HRS 2010 – Denver presentations

Dr. Wojciech Zareba from the University of Rochester refers to an ongoing NIH-sponsored trial of MTWA in MADIT-II patients.

MTWA in risk stratification of CDM patients: can it help to better select candidates for ICD implantation? First experience of a single Belgian Center (Belgium Congress of Cardiology 2010)

Gene Expression Identifies Molecular Mechanism and Therapeutic Target for Arrhythmogenic Cardiac Alternans

(Circ Arrhythm Electrophysiol. 2009;2:686-694.)

PREVENT-SCD trial, presented at the American Heart Association Scientific Sessions in Orlando, Florida, reinforce the value of the Microvolt T-wave Alternans test in identifying patients at risk of sudden cardiac death (SCD).




 "Indeterminate" Microvolt T-Wave Alternans Tests Predict High Risk of Death or Sustained Ventricular Arrhythmias in Patients With Left Ventricular Dysfunction



 NIH Sponsored Study in JACC Extends Predictive Ability of Microvolt T-Wave Alternans; Non-invasive study shown effective in identifying patients both at high and low risk of sudden cardiac death (J Am Coll Cardiol, 2006; 47:456-463)


For additional information:




 Review of Key Clinical Literature (pdf)

Use of MTWA in Clinical Practice

NEW POWERPOINT PRESENTATIONC:\Users\pc\My Documents\WEBPAGE\EPLabDigest-2001.pdf



Editor Comments on MMA Method

C:\Users\pc\Desktop\BACKUP\TWA\WEBPAGE\MMA Method.htmC:\Users\pc\My Documents\WEBPAGE\searchPage.htmC:\Users\pc\My Documents\WEBPAGE\Pagine da VT MTWA2005.pdf

ACC/AHA/ESC Guidelines for the Management of Patients with Ventricular Arrhythmias and the Prevention of Cardiac Death – Extracted Sections on  T Wave Alternans in Class 2a (Level of Evidence A): All reference papers are based on the Spectral Analytic MethodC:\Users\pc\My Documents\WEBPAGE\ReviewKCL2002.pdfC:\Users\pc\My Documents\WEBPAGE\ReviewKCL2002.pdf






Additional Info on T Wave Alternans products : http://www.cambridgeheart.com

Automatic update on new papers : dmarangoni@tin.it


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