Expert Commentary from T. Chow paper:
“The weight of the literature
suggests that MTWA is a powerful predictor of total and arrhythmic mortality –
but not ICD shocks. As such, it provides the clinician additional
information that helps them make rational decisions about ICD therapy. MTWA
does not replace ICD treatment guidelines, but complements it. In my
opinion, MTWA is most useful today in determining what to do with borderline
indicated patients, or those with a shortened time frame for ICD benefit due to
co-morbid illness or advanced age. It is a good practical tool to
introduce the topic of SCD risk to the stable patient, or reinforce the risk
lurking beneath the surface to the reluctant patient. MTWA
as a risk stratifier sits somewhere between
cholesterol – where firm guidelines and treatment algorithms exist – and
inflammatory biomarkers – which are nonspecific and
not required, but potentially useful for the thoughtful physician.
MTWA is physiologically linked to ventricular arrhythmias, and should be
considered an additional tool in assessing the patient whose risk for SCD needs
further clarification. How often this occurs practically is dependent
upon practice style – it will be less useful for aggressive physicians who
generally implant without consideration to risk stratification, but more useful
for the majority of physicians who already practice ICD risk stratification,
even though it is not commonly referred to as such. For these physicians,
MTWA provides a method for more accurately tailoring treatment to the individual
patient.”
“In an era of ever-declining
physician reimbursement there are always concerns that additional testing might
reduce implant rates, further lowering physician income. Since no studies
exist on this topic, I can only cite extensive personal experience and
observation of others who have used this technology to conclude that the effect
of MTWA on the ‘business’ aspect of medicine is entirely related to how it is
deployed. If one uses it to restrict devices, that it what will happen.
If one uses it to recruit marginal increases in implants through improved
patient and physician acceptance of ICD need, this is what will happen. In
this respect, MTWA does what is asked of it.”