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.”