European Heart Journal Advance Access originally published online on July 25, 2007
European Heart Journal 2007 28(19):2332-2337; doi:10.1093/eurheartj/ehm271
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T-wave alternans predicts mortality in a population undergoing a clinically indicated exercise test
1 Department of Pharmacological Sciences, Medical School, University of Tampere, Tampere, Finland
2 Laboratory of Atherosclerosis Genetics, Department of Clinical Chemistry, Tampere University Hospital, Tampere, Finland
3 Medical School, University of Tampere, Tampere, Finland
4 Ragnar Granit Institute, Tampere University of Technology, Tampere, Finland
5 Department of Clinical Physiology, Tampere University Hospital, FI-33520 Tampere, Finland
6 Tampere Polytechnic, University of Applied Sciences, Tampere, Finland
7 Heart Centre, Department of Cardiology, Tampere University Hospital, Tampere, Finland
8 GE Healthcare Information Technologies, Freiburg, Germany
9 School of Public Health, University of Tampere, Tampere, Finland
10 Harvard Medical School, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA
11 Department of Medicine, University of Oulu, Oulu, Finland
Received 16 January 2007; revised 21 May 2007; accepted 7 June 2007; online publish-ahead-of-print 25 July 2007.
* Corresponding author. Tel: +358 3 311 65394; fax: +358 3 311 65511. E-mail address: mika.kahonen{at}uta.fi
See page 2303 for the editorial comment on this article (doi:10.1093/eurheartj/ehm350)
Aims: As a part of the Finnish Cardiovascular Study, we tested the hypothesis that T-wave alternans (TWA) predicts mortality in a general population of patients referred for a clinical exercise test.
Methods and results: A total of 1037 consecutive patients (mean age ± SD of 58 ± 13 years, 673 men and 364 women) with a clinically indicated exercise test and with technically successful electrocardiographic (ECG) data during a bicycle ergometer test were included in the study. Digital ECGs were recorded and TWA was analysed continuously with the time-domain modified moving average method. The maximum TWA value at heart rate (HR) <125 b.p.m. was derived and its capacity to stratify risk for all-cause death, cardiovascular death, and sudden cardiac death (SCD) was tested. During a follow-up of 44 ± 7 months (mean ± SD), 59 patients died; 34 were due to cardiovascular causes and 20 were due to SCD. In multivariate analysis after adjustment for age, sex, use of ß-blockers, functional class, maximal HR during exercise, previous myocardial infarction, and other common coronary risk factors, the relative risk of TWA 
65 µV for SCD was 7.4 (95% CI, 2.8–19.4; P < 0.001), for cardiovascular mortality 6.0 (95% CI, 2.8–12.8; P < 0.001), and for all-cause mortality 3.3 (95% CI, 1.8–6.3; P = 0.001).
Conclusion: Time-domain TWA analysis powerfully predicts mortality in a general population undergoing a clinical exercise test.
Key Words: Arrhythmia • Electrocardiography • Exercise • Mortality • Tachyarrhythmia
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