-wave alternans (TWA) has been employed in the selection of patients considered for cardioverter/defibrillator (ICD) implantation, and has been found to have an excellent negative predictive value for sudden death and malignant ventricular arrhythmias in patients with a variety of cardiac pathologies [1]. Although a qualitative approach in the characterization of patients with TWA positive or negative results has prevailed, based on a threshold of ≥1.9 μV, attained during exercise stress testing, employing the frequency domain analysis [2], some have advanced the argument that employment of TWA in quantitative terms may have advantages [3,4]. Indeed even the currently employed qualitative (yes or no) spectral analysis method with the ≥1.9 μV threshold value has a quantitative underpinning, in the sense that non attainment of the threshold value of ≥1.9 μV renders the patient's test negative [2]. Intuitively the magnitude of TWA must be of importance not only because a particular threshold needs to be reached, before the patient is considered positive, but because pathophysiological derangements (e.g., ischemia, volume overload, or myocardial necrosis) result in an increase of the magnitude of TWA or an association of the magnitude of the TWA and the severity of derangement [5-7], while therapeutic interventions (e.g. beta-blockers) lead to a decrease in the magnitude of TWA [8]
