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T wave (repolarization) alternans: Clinical aspects

Sanjiv M Narayan, MD, PhD
Section Editor
Ary L Goldberger, MD
Deputy Editor
Brian C Downey, MD, FACC


Clinical risk stratification for sudden cardiac death typically focuses on the presence of a reduced left ventricular ejection fraction and the presence of heart failure. However, these parameters identify only a minority of individuals who will die suddenly, and also identify others who will not suffer lethal ventricular arrhythmias [1,2]. As a result, there is continued interest in additional electrophysiologic indices for risk prediction, of which one of the most promising remains T-wave alternans (TWA) [2].

TWA refers to beat-to-beat variability in the timing or shape of T-waves on the surface electrocardiogram (ECG) [1,2]. TWA reflects temporal heterogeneity or dispersion in ventricular repolarization, which is an important mechanism underlying reentrant arrhythmias [3,4]. Several studies suggest that TWA may add value to signal-averaged ECG, heart rate variability, and other indices. TWA is approved by the United States Food and Drug Administration (FDA) for noninvasively predicting the risk for life-threatening ventricular arrhythmias [5].

The clinical utility of TWA will be reviewed here. The technical aspects and methods for analyzing TWA are discussed separately. (See "T wave (repolarization) alternans: Technical aspects".)


TWA is primarily used as a tool for the risk stratification for sudden cardiac death (SCD) [6]. Most of the focus of such efforts has been on patients with prior myocardial infarction, reduced left ventricular (LV) ejection fraction, and/or symptomatic heart failure [7-9]. More recently, TWA has been studied in more diverse populations.

Historically, studies of TWA may be divided into three phases:


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Literature review current through: Sep 2016. | This topic last updated: Oct 21, 2015.
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