Clinical Research
Clinical Trial
The ABCD (Alternans Before Cardioverter Defibrillator) Trial: Strategies Using T-Wave Alternans to Improve Efficiency of Sudden Cardiac Death Prevention

This work was presented in part at the annual Scientific Sessions of the American Heart Association, Chicago, Illinois, in November 2006.
https://doi.org/10.1016/j.jacc.2008.08.077Get rights and content
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Objectives

Because risk stratification with electrophysiological study (EPS) improves efficiency but is invasive, we sought to determine whether noninvasive microvolt T-wave alternans (MTWA) testing could identify patients who benefit from implantable cardioverter-defibrillators (ICDs) as well as EPS.

Background

Prevention of sudden cardiac death on the basis of left ventricular ejection fraction (LVEF) alone is inefficient, because most ICDs never deliver therapy.

Methods

The ABCD (Alternans Before Cardioverter Defibrillator) trial is a multicenter prospective study that enrolled patients with ischemic cardiomyopathy (LVEF ≤0.40) and nonsustained ventricular tachycardia. All patients underwent MTWA and EPS. ICDs were mandated if either test was positive.

Results

Of 566 patients followed for a median of 1.9 years, 39 (7.5%) met the primary end point of appropriate ICD discharge or sudden death at 1 year. As hypothesized, primary analysis showed that MTWA achieved 1-year positive (9%) and negative (95%) predictive values that were comparable to EPS (11% and 95%, respectively). In addition, secondary analysis showed that at the pre-specified 1-year end point, event rates were significantly higher in patients with both a positive MTWA-directed strategy (hazard ratio: 2.1, p = 0.03) and a positive EPS-directed strategy (hazard ratio: 2.4, p = 0.007). Moreover, the event rate in patients with both negative MTWA test and EPS was lower than in those with 2 positive tests (2% vs. 12%; p = 0.017).

Conclusions

The ABCD study is the first trial to use MTWA to guide prophylactic ICD insertion. Risk stratification strategies using noninvasive MTWA versus invasive EPS are comparable at 1 year and complementary when applied in combination. Strategies employing MTWA, EPS, or both might identify subsets of patients least likely to benefit from ICD insertion. (Study to Compare TWA Test and EPS Test for Predicting Patients at Risk for Life-Threatening Heart Rhythms [ABCD Study]; NCT00187291)

Key Words

coronary disease
electrophysiological study
sudden death
T-wave alternans

Abbreviations and Acronyms

ATP
antitachycardia pacing
EPS
electrophysiological study
HR
hazard ratio
ICD
implantable cardioverter-defibrillator
LVEF
left ventricular ejection fraction
MTWA
microvolt T-wave alternans
NPV
negative predictive value
NSVT
nonsustained ventricular tachycardia
PPV
positive predictive value
SCD
sudden cardiac death

Cited by (0)

Sponsorship was provided by St. Jude Medical CRMD. Dr. Rosenbaum serves as a consultant to and receives honoraria from Cambridge Heart, Inc. Dr. Sethuraman is an employee of St. Jude, Inc. Dr. Lerman is a consultant to GE Healthcare and Biosense Webster. Drs. Costantini and Rosenbaum contributed equally to this work.