Feasibility/eligibility of T-wave alternans testing in patients with heart failure: should we rethink our current modus operandi?: reply

We appreciate the interest of Dr Madias in our study regarding microvolt T-wave alternans testing. He addresses the important issue of eligibility for MTWA testing and identifies several recent studies where a large proportion of unselected patients have been ineligible for MTWA testing. However, Dr Madias suggests that implantable cardioverter-defibrillators (ICDs) may be recommended for certain patients including those ineligible for MTWA testing and proposes that MTWA testing may have a role in specific settings. There is no evidence to support any role for MTWA in the contemporary risk stratification of patients with heart failure. At present the use of MTWA testing can be justified for research purposes only. Patients should not be exposed to a test that has never been shown to be of any clinical value. An ICD should only be considered in patients fulfilling the evidence-based criteria laid out in guidelines