1
|
Nagase S, Oka S, Kamakura T, Aiba T, Morita H, Kusano K. Local dispersion of repolarization in the occurrence of ventricular fibrillation in Brugada syndrome: Possibility of phase 2 reentry? Pacing Clin Electrophysiol 2024; 47:1049-1053. [PMID: 38214176 DOI: 10.1111/pace.14917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/30/2023] [Accepted: 12/21/2023] [Indexed: 01/13/2024]
Abstract
To date, there have been no reports of recording epicardial electrograms at the onset of spontaneous ventricular fibrillation (VF) in patients with Brugada syndrome (BrS). In the case of BrS, unipolar and bipolar electrogram recording on the right ventricular epicardium revealed that dispersion of repolarization with delayed potential was associated with spontaneous occurrence of VF. Phase 2 reentry associated with shortening and dispersion of action potential could have been recorded for the first time in BrS. Epicardial unipolar mapping can guide accurate and appropriate ablation for the elimination of arrhythmia substrate in J wave syndrome.
Collapse
Affiliation(s)
- Satoshi Nagase
- Department of Advanced Arrhythmia and Translational Medical Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Oka
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tsukasa Kamakura
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kengo Kusano
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| |
Collapse
|
2
|
Nagase S, Kataoka N, Morita H, Kamakura T, Ueoka A, Nakamura T, Oka S, Miyazaki Y, Wakamiya A, Nakajima K, Ueda N, Wada M, Ishibashi K, Inoue Y, Miyamoto K, Aiba T, Kusano K. Demonstration of Arrhythmia Substrate-Associated Dispersion of Repolarization by Epicardial Unipolar Mapping in Brugada Syndrome. JACC Clin Electrophysiol 2024; 10:1576-1588. [PMID: 38864810 DOI: 10.1016/j.jacep.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Epicardial unipolar mapping has not been thoroughly investigated in Brugada syndrome (BrS). OBJECTIVES This study aims to examine the characteristics of epicardial unipolar potentials in BrS and investigate the differences from overt cardiomyopathy. METHODS Epicardial mapping was performed in 8 patients with BrS and 6 patients with cardiomyopathy. We investigated the J-wave amplitudes using unipolar recordings at delayed potential (DP) sites via bipolar recordings. The repolarization time (RT) at and around the DP recording sites was measured, and maximum dispersion of the RT divided by the distance was defined as the RT dispersion index. RESULTS Epicardial mapping at baseline revealed significantly higher J-wave amplitude with bipolar DP in patients with BrS than in patients with cardiomyopathy. J-wave amplitude ≥0.42 mV had 99.1% sensitivity and 100% specificity for diagnosing BrS. The RT dispersion index was significantly higher in patients with BrS than in patients with cardiomyopathy at baseline. In all patients with BrS, coved-type unipolar electrograms without negative T waves (short RT) appeared close to coved-type electrograms with negative T waves (long RT) at the DP recording sites after pilsicainide administration. Thus, a steep RT dispersion was observed in this region, and ventricular arrhythmias emerged from this shorter RT area in all 3 patients with BrS in whom ventricular arrhythmias were induced. CONCLUSIONS Bipolar DP-related prominent unipolar J waves and steep repolarization gradients may be more specific for characterizing BrS than for overt cardiomyopathy. Ventricular arrhythmias in BrS are associated with a steep repolarization gradient, indicating phase 2 re-entry as a possible cause.
Collapse
Affiliation(s)
- Satoshi Nagase
- Department of Advanced Arrhythmia and Translational Medical Science, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tsukasa Kamakura
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akira Ueoka
- Department of Cardiovascular Medicine, Dentistry and Pharmaceutical Sciences, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
| | - Toshihiro Nakamura
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Oka
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuichiro Miyazaki
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akinori Wakamiya
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenzaburo Nakajima
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobuhiko Ueda
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mitsuru Wada
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kohei Ishibashi
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuko Inoue
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koji Miyamoto
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kengo Kusano
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| |
Collapse
|
3
|
Zhang Z, Brugada P, Weiss JN, Qu Z. Phase 2 Re-Entry Without I to: Role of Sodium Channel Kinetics in Brugada Syndrome Arrhythmias. JACC Clin Electrophysiol 2023; 9:2459-2474. [PMID: 37831035 PMCID: PMC11348283 DOI: 10.1016/j.jacep.2023.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/27/2023] [Accepted: 08/23/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND In Brugada syndrome (BrS), phase 2 re-excitation/re-entry (P2R) induced by the transient outward potassium current (Ito) is a proposed arrhythmia mechanism; yet, the most common genetic defects are loss-of-function sodium channel mutations. OBJECTIVES The authors used computer simulations to investigate how sodium channel dysfunction affects P2R-mediated arrhythmogenesis in the presence and absence of Ito. METHODS Computer simulations were carried out in 1-dimensional cables and 2-dimensional tissue using guinea pig and human ventricular action potential models. RESULTS In the presence of Ito sufficient to generate robust P2R, reducing sodium current (INa) peak amplitude alone only slightly potentiated P2R. When INa inactivation kinetics were also altered to simulate reported effects of BrS mutations and sodium channel blockers, however, P2R occurred even in the absence of Ito. These effects could be potentiated by delaying L-type calcium channel activation or increasing ATP-sensitive potassium current, consistent with experimental and clinical findings. INa-mediated P2R also accounted for sex-related, day and night-related, and fever-related differences in arrhythmia risk in BrS patients. CONCLUSIONS Altered INa kinetics synergize powerfully with reduced INa amplitude to promote P2R-induced arrhythmias in BrS in the absence of Ito, establishing a robust mechanistic link between altered INa kinetics and the P2R-mediated arrhythmia mechanism.
Collapse
Affiliation(s)
- Zhaoyang Zhang
- Department of Physics, School of Physical Science and Technology, Ningbo University, Ningbo, Zhejiang, China; Division of Cardiology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Pedro Brugada
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - James N Weiss
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Zhilin Qu
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA.
| |
Collapse
|
4
|
Kamara J, Ponnusamy S, Licenik R, Nwabufor PC, Rather MI. An Unusual First Presentation of Stroke and Seizure in a 32-Year-Old Patient With Brugada Syndrome Type 2 Electrocardiogram Pattern. Cureus 2023; 15:e44630. [PMID: 37799229 PMCID: PMC10548144 DOI: 10.7759/cureus.44630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 10/07/2023] Open
Abstract
We report a case of a 32-year-old lady who was admitted to the hospital with right-sided weakness that preceded an episode of seizure. On the day of admission, she woke up early in the morning with mild right-sided weakness and numbness. She had difficulty walking and later had a seizure, which was witnessed by her son. She had no signs of infection prior to this. She had no fever, chest or abdominal pain, or urinary symptoms. In the emergency department, she complained of left-sided chest tightness and heaviness, which lasted for a few minutes with associated tachycardia, electrocardiogram (ECG) was consistent with Brugada syndrome type 2. A magnetic resonant imaging (MRI) scan of her head shows a left hemispheric infarct involving the frontoparietal cortex. She was treated for an ischaemic stroke and seizure. She made a good recovery and was discharged home on secondary stroke prevention medication with community physiotherapy. She was followed up in the cardiology, genetics, and stroke outpatient clinics. The occurrence of ECG changes consistent with Brugada syndrome, stroke, and seizure in a young patient with no other risk factors for stroke is rare.
Collapse
Affiliation(s)
- John Kamara
- Cardiology, Peterborough City Hospital, Peterborough, GBR
| | | | - Radim Licenik
- Stroke, Peterborough City Hospital, Peterborough, GBR
| | | | | |
Collapse
|
5
|
Melgari D, Calamaio S, Frosio A, Prevostini R, Anastasia L, Pappone C, Rivolta I. Automated Patch-Clamp and Induced Pluripotent Stem Cell-Derived Cardiomyocytes: A Synergistic Approach in the Study of Brugada Syndrome. Int J Mol Sci 2023; 24:ijms24076687. [PMID: 37047659 PMCID: PMC10095337 DOI: 10.3390/ijms24076687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
The development of high-throughput automated patch-clamp technology is a recent breakthrough in the field of Brugada syndrome research. Brugada syndrome is a heart disorder marked by abnormal electrocardiographic readings and an elevated risk of sudden cardiac death due to arrhythmias. Various experimental models, developed either in animals, cell lines, human tissue or computational simulation, play a crucial role in advancing our understanding of this condition, and developing effective treatments. In the perspective of the pathophysiological role of ion channels and their pharmacology, automated patch-clamp involves a robotic system that enables the simultaneous recording of electrical activity from multiple single cells at once, greatly improving the speed and efficiency of data collection. By combining this approach with the use of patient-derived cardiomyocytes, researchers are gaining a more comprehensive view of the underlying mechanisms of heart disease. This has led to the development of more effective treatments for those affected by cardiovascular conditions.
Collapse
Affiliation(s)
- Dario Melgari
- Institute of Molecular and Translational Cardiology (IMTC), San Donato Milanese, 20097 Milan, Italy
| | - Serena Calamaio
- Institute of Molecular and Translational Cardiology (IMTC), San Donato Milanese, 20097 Milan, Italy
| | - Anthony Frosio
- Institute of Molecular and Translational Cardiology (IMTC), San Donato Milanese, 20097 Milan, Italy
| | - Rachele Prevostini
- Institute of Molecular and Translational Cardiology (IMTC), San Donato Milanese, 20097 Milan, Italy
| | - Luigi Anastasia
- Institute of Molecular and Translational Cardiology (IMTC), San Donato Milanese, 20097 Milan, Italy
- Faculty of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Carlo Pappone
- Institute of Molecular and Translational Cardiology (IMTC), San Donato Milanese, 20097 Milan, Italy
- Faculty of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Ilaria Rivolta
- Institute of Molecular and Translational Cardiology (IMTC), San Donato Milanese, 20097 Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, 20900 Monza, Italy
| |
Collapse
|
6
|
Li Y, Lang S, Akin I, Zhou X, El-Battrawy I. Brugada Syndrome: Different Experimental Models and the Role of Human Cardiomyocytes From Induced Pluripotent Stem Cells. J Am Heart Assoc 2022; 11:e024410. [PMID: 35322667 PMCID: PMC9075459 DOI: 10.1161/jaha.121.024410] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Brugada syndrome (BrS) is an inherited and rare cardiac arrhythmogenic disease associated with an increased risk of ventricular fibrillation and sudden cardiac death. Different genes have been linked to BrS. The majority of mutations are located in the SCN5A gene, and the typical abnormal ECG is an elevation of the ST segment in the right precordial leads V1 to V3. The pathophysiological mechanisms of BrS were studied in different models, including animal models, heterologous expression systems, and human-induced pluripotent stem cell-derived cardiomyocyte models. Currently, only a few BrS studies have used human-induced pluripotent stem cell-derived cardiomyocytes, most of which have focused on genotype-phenotype correlations and drug screening. The combination of new technologies, such as clustered regularly interspaced short palindromic repeats (CRISPR)/Cas9 (CRISPR associated protein 9)-mediated genome editing and 3-dimensional engineered heart tissues, has provided novel insights into the pathophysiological mechanisms of the disease and could offer opportunities to improve the diagnosis and treatment of patients with BrS. This review aimed to compare different models of BrS for a better understanding of the roles of human-induced pluripotent stem cell-derived cardiomyocytes in current BrS research and personalized medicine at a later stage.
Collapse
Affiliation(s)
- Yingrui Li
- First Department of Medicine Medical Faculty Mannheim University Medical Centre Mannheim (UMM)University of Heidelberg Mannheim Germany
| | - Siegfried Lang
- First Department of Medicine Medical Faculty Mannheim University Medical Centre Mannheim (UMM)University of Heidelberg Mannheim Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim Mannheim Germany
| | - Ibrahim Akin
- First Department of Medicine Medical Faculty Mannheim University Medical Centre Mannheim (UMM)University of Heidelberg Mannheim Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim Mannheim Germany
| | - Xiaobo Zhou
- First Department of Medicine Medical Faculty Mannheim University Medical Centre Mannheim (UMM)University of Heidelberg Mannheim Germany.,Key Laboratory of Medical Electrophysiology of Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province Institute of Cardiovascular Research Southwest Medical University Luzhou Sichuan China.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim Mannheim Germany
| | - Ibrahim El-Battrawy
- First Department of Medicine Medical Faculty Mannheim University Medical Centre Mannheim (UMM)University of Heidelberg Mannheim Germany.,DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg-Mannheim Mannheim Germany.,Department of Cardiology and Angiology Bergmannsheil Bochum Medical Clinic II Ruhr University Bochum Germany
| |
Collapse
|
7
|
Scrocco C, Ben-Haim Y, Devine B, Tome-Esteban M, Papadakis M, Sharma S, Macfarlane PW, Behr ER. Role of subcutaneous implantable loop recorder for the diagnosis of arrhythmias in Brugada syndrome: A United Kingdom single-center experience. Heart Rhythm 2021; 19:70-78. [PMID: 34487893 DOI: 10.1016/j.hrthm.2021.08.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 08/09/2021] [Accepted: 08/22/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Experience with implantable loop recorders (ILRs) in Brugada syndrome (BrS) is limited. OBJECTIVE The purpose of this study was to evaluate the indications and yield of ILR monitoring in a single-center BrS registry. METHODS Demographic, clinical and follow-up data of BrS patients with ILR were collected. RESULTS Of 415 BrS patients recruited consecutively, 50 (12%) received an ILR (58% male). Mean age at ILR implantation was 44 ± 15 years. Thirty-one (62%) had experienced syncopal or presyncopal episodes, and 23 (46%) had palpitations. During median follow-up of 28 months (range 1-68), actionable events were detected in 11 subjects (22%); 7 had recurrences of syncope/presyncope, with 4 showing defects in sinus node function or atrioventricular conduction. New supraventricular tachyarrhythmias were recorded in 6 subjects; a run of fast nonsustained ventricular tachycardia was detected in 1 patient. Patients implanted with an ILR were less likely to show a spontaneous type 1 pattern or depolarization electrocardiographic (ECG) abnormalities compared to those receiving a primary prevention implantable-cardioverter defibrillator. Age at implantation, gender, Shanghai score, and ECG parameters did not differ between subjects with and those without actionable events. ILR-related complications occurred in 3 cases (6%). CONCLUSION In a large cohort of BrS patients, continuous ILR monitoring yielded a diagnosis of tachy- or bradyarrhythmic episodes in 22% of cases. Recurrences of syncope were associated with bradyarrhythmic events. Use of ILR can be helpful in guiding the management of low-/intermediate-risk BrS patients and ascertaining the cause of unexplained syncope.
Collapse
Affiliation(s)
- Chiara Scrocco
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Yael Ben-Haim
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Brian Devine
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Maite Tome-Esteban
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sanjay Sharma
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Peter W Macfarlane
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Elijah R Behr
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom.
| |
Collapse
|
8
|
Shinohara T, Takagi M, Kamakura T, Sekiguchi Y, Yokoyama Y, Aihara N, Hiraoka M, Aonuma K. Risk stratification in asymptomatic patients with Brugada syndrome: Utility of multiple risk factor combination rather than programmed electrical stimulation. J Cardiovasc Electrophysiol 2020; 32:507-514. [PMID: 33368830 DOI: 10.1111/jce.14848] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/24/2020] [Accepted: 12/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The prognostic value of programmed electrical stimulation (PES) in Brugada syndrome (BrS) remains controversial. Asymptomatic BrS patients generally have a better prognosis than those with symptoms. The purpose of this study was to evaluate the value of nonaggressive PES with up to two extra stimuli and predict clinical factors for risk stratification in asymptomatic BrS patients. METHODS The study enrolled 193 consecutive asymptomatic BrS patients with type 1 ECG (mean age: 50 ± 13 years, 180 males) who underwent PES using a nonaggressive uniform protocol. Cardiac events (CEs: sudden cardiac death or ventricular tachyarrhythmia) during the follow-up period were examined. RESULTS During a mean follow-up of 101 ± 48 months, seven asymptomatic patients (3.6%) had a CE. The incidence of CEs was not different between patients with and without inducible ventricular tachyarrhythmia by PES (p = .51). The clinical significance of risk factor combinations, including spontaneous type 1 ECG, family history of sudden cardiac death, QRS duration in lead V2 , and presence of J wave, was evaluated. Using the Kaplan-Meier method according to the number of risk factors, the prevalence of CE in patients with three or four risk factors was determined to be significantly higher than in those with one risk factor (p = .02 and p = .004, respectively). CONCLUSIONS The present study suggests that inducibility of ventricular tachyarrhythmia does not predict future CEs in asymptomatic BrS patients. Combination analysis of the other four clinical risk parameters may be effective for risk assessment.
Collapse
Affiliation(s)
- Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
| | - Masahiko Takagi
- Department of Medicine II, Kansai Medical University, Moriguchi, Japan
| | - Tsukasa Kamakura
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Suita, Japan
| | - Yukio Sekiguchi
- Cardiovascular Division, Department of Internal Medicine, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yasuhiro Yokoyama
- Division of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Naohiko Aihara
- Department of Internal Medicine, Senri Central Hospital, Suita, Japan
| | - Masayasu Hiraoka
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazutaka Aonuma
- Cardiovascular Division, Department of Internal Medicine, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Japan
| | | |
Collapse
|
9
|
Morita H, Asada ST, Miyamoto M, Morimoto Y, Kimura T, Mizuno T, Nakagawa K, Watanabe A, Nishii N, Ito H. Significance of Exercise-Related Ventricular Arrhythmias in Patients With Brugada Syndrome. J Am Heart Assoc 2020; 9:e016907. [PMID: 33222599 PMCID: PMC7763771 DOI: 10.1161/jaha.120.016907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Sinus tachycardia during exercise attenuates ST‐segment elevation in patients with Brugada syndrome, whereas ST‐segment augmentation after an exercise test is a high‐risk sign. Some patients have premature ventricular contractions (PVCs) related to exercise, but the significance of exercise‐related PVCs in patients with Brugada syndrome is still unknown. The objective of this study was to determine the significance of exercise‐related PVCs for predicting occurrence of ventricular fibrillation (VF) in patients with Brugada syndrome. Methods and Results The subjects were 307 patients with Brugada syndrome who performed a treadmill exercise test. We evaluated the occurrence of PVCs at rest, during exercise and at the peak of exercise, and during recovery after exercise (0–5 minutes). We followed the patients for 92±68 months and evaluated the occurrence of VF. PVCs occurred in 82 patients (27%) at the time of treadmill exercise test: PVCs appeared at rest in 14 patients (4%), during exercise in 60 patients (20%), immediately after exercise (0–1.5 minutes) in 28 patients (9%), early after exercise (1.5–3 minutes) in 18 patients (6%), and late after exercise (3–5 minutes) in 12 patients (4%). Thirty patients experienced VF during follow‐up. Multivariable analysis including symptoms, spontaneous type 1 ECG, and PVCs in the early recovery phase showed that these factors were independently associated with VF events during follow‐up. Conclusions PVCs early after an exercise test are associated with future occurrence of VF events. Rebound of vagal nerve activity at the early recovery phase would promote ST‐segment augmentation and PVCs in high‐risk patients with Brugada syndrome.
Collapse
Affiliation(s)
- Hiroshi Morita
- Department of Cardiovascular Therapeutics Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Saori T Asada
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Masakazu Miyamoto
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Yoshimasa Morimoto
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Tomonari Kimura
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Tomofumi Mizuno
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Nobuhiro Nishii
- Department of Cardiovascular Therapeutics Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| |
Collapse
|
10
|
Abstract
Brugada syndrome is an inherited, rare cardiac arrhythmogenic disease, associated with sudden cardiac death. It accounts for up to 20% of sudden deaths in patients without structural cardiac abnormalities. The majority of mutations involve the cardiac sodium channel gene SCN5A and give rise to classical abnormal electrocardiogram with ST segment elevation in the right precordial leads V1 to V3 and a predisposition to ventricular fibrillation. The pathophysiological mechanisms of Brugada syndrome have been investigated using model systems including transgenic mice, canine heart preparations, and expression systems to study different SCN5A mutations. These models have a number of limitations. The recent development of pluripotent stem cell technology creates an opportunity to study cardiomyocytes derived from patients and healthy individuals. To date, only a few studies have been done using Brugada syndrome patient-specific iPS-CM, which have provided novel insights into the mechanisms and pathophysiology of Brugada syndrome. This review provides an evaluation of the strengths and limitations of each of these model systems and summarizes the key mechanisms that have been identified to date.
Collapse
|
11
|
Progression of electrocardiographic abnormalities associated with initial ventricular fibrillation in asymptomatic patients with Brugada syndrome. Heart Rhythm 2018; 15:1468-1474. [DOI: 10.1016/j.hrthm.2018.06.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Indexed: 11/21/2022]
|
12
|
Evaluation of baseline ECG in patients undergoing Oral Flecainide Challenge test for suspected Brugada Syndrome: An analysis of lead II. Indian Pacing Electrophysiol J 2017; 17:102-107. [PMID: 29067908 PMCID: PMC5527819 DOI: 10.1016/j.ipej.2017.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/18/2017] [Accepted: 04/23/2017] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives We analyzed Lead II in patients undergoing an Oral Flecainide Challenge test (FCT), to identify any pointers that could predict a positive FCT and thereby help in recognition of latent BS. Methods The following parameters in lead II were retrospectively analyzed from the pre-test ECG in 62 patients undergoing FCT for suspected BS: The presence or absence of S waves, S wave amplitude, duration and upslope duration; J point parameters- Early repolarization, QRS notch, and QRS Slur; ST segment parameters-lack of isoelectric ST segment, ST duration and QT interval. Results 48 had positive FCT (Group-1) while 14 were negative for FCT(Group-2). Lack of an isoelectric ST segment (50% vs 14.29%, p = 0.018) and slurring of QRS (33.33% vs 0%, p = 0.014) was more common in Group-1 than Group-2. Group-1 had shorter ST segment duration (median 81.5 (IQR 64–103.5) vs 110 (IQR 90–132), p = 0.002) and shorter ST: QT ratio (median 0.28 (IQR 0.22–0.35) vs 0.23 (0.18–0.27), p = 0.007). QRS notch/depressed J point (87.5%), QRS slur (100%), and lack of isoelectric ST segment (92.31%) had high sensitivity for predicting an inducible Type 1 Brugada pattern. Combining two parameters- ST: QT ratio<0.24 and lack of isoelectric ST segment-considerably improved the specificity (73.3%), and the positive predictive value of the test to 76%. The results remained accurate when validated in a small prospective cohort. Conclusion Shortened ST segment in Lead II, lack of isoelectric ST segment, slurred QRS and ST/QT ratio <0.24 are predictive of underlying Brugada pattern in baseline ECG.
Collapse
|
13
|
Komatsu M, Takahashi J, Fukuda K, Takagi Y, Shiroto T, Nakano M, Kondo M, Tsuburaya R, Hao K, Nishimiya K, Nihei T, Matsumoto Y, Ito K, Sakata Y, Miyata S, Shimokawa H. Usefulness of Testing for Coronary Artery Spasm and Programmed Ventricular Stimulation in Survivors of Out-of-Hospital Cardiac Arrest. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.115.003798. [DOI: 10.1161/circep.115.003798] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 08/04/2016] [Indexed: 11/16/2022]
Abstract
Background—
Optimal therapy for patients resuscitated from out-of-hospital cardiac arrest (OHCA) who are not found to have structural heart disease remains to be established, especially regarding the use of implantable cardioverter-defibrillators. Coronary artery spasm (CAS) and lethal ventricular arrhythmias are important causes of OHCA.
Methods and Results—
In 47 consecutive OHCA survivors without structural heart disease who had fully recovered (M/F 44/3, 43±13 years.), we performed dual induction tests, including acetylcholine provocation test first followed by programmed ventricular stimulation after 1 to 2 weeks. Patients with CAS were treated with calcium channel blocker–based antianginal medications; implantable cardioverter-defibrillators were implanted in all patients. The results of the dual induction tests defined 4 groups: CAS alone (n=7), inducible ventricular arrhythmias alone (n=13), both positive (n=24), and both negative (n=3). During a median follow-up period of 38 months, ventricular fibrillation recurred in all groups except the both-negative group. Of the 16 patients with a type I Brugada ECG, 2 had CAS alone, 8 had ventricular arrhythmias alone, and 6 had both positive. No ventricular fibrillation episodes were observed in the CAS-alone patients who did not also have Brugada syndrome. Kaplan–Meier analysis showed that the CAS-alone group was at lower risk for OHCA recurrence as compared with the Brugada syndrome group (log-rank test;
P
=0.036).
Conclusions—
Among OHCA survivors without structural heart disease, provokable CAS and ventricular arrhythmias are common and can be seen in Brugada syndrome. CAS alone without Brugada syndrome who are treated for CAS may be a lower-risk group.
Collapse
Affiliation(s)
- Masayasu Komatsu
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Takahashi
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Koji Fukuda
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yusuke Takagi
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Shiroto
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Makoto Nakano
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masateru Kondo
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryuji Tsuburaya
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kiyotaka Hao
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kensuke Nishimiya
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Taro Nihei
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuharu Matsumoto
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenta Ito
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiko Sakata
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Satoshi Miyata
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimokawa
- From the Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| |
Collapse
|
14
|
Ueoka A, Morita H, Watanabe A, Nakagawa K, Nishii N, Nagase S, Ohe T, Ito H. Activation Pattern of the Polymorphic Ventricular Tachycardia and Ventricular Fibrillation on Body Surface Mapping in Patients With Brugada Syndrome. Circ J 2016; 80:1734-43. [DOI: 10.1253/circj.cj-16-0124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akira Ueoka
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine and Dentistry
| | - Hiroshi Morita
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine and Dentistry
| | - Atsuyuki Watanabe
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine and Dentistry
| | - Koji Nakagawa
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine and Dentistry
| | - Nobuhiro Nishii
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine and Dentistry
| | - Satoshi Nagase
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine and Dentistry
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tohru Ohe
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine and Dentistry
- Department of Cardiovascular Medicine, Cardiovascular Center Sakakibara Hospital
| | - Hiroshi Ito
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine and Dentistry
| |
Collapse
|
15
|
Naseef A, Behr ER, Batchvarov VN. Electrocardiographic methods for diagnosis and risk stratification in the Brugada syndrome. J Saudi Heart Assoc 2015; 27:96-108. [PMID: 25870503 PMCID: PMC4392351 DOI: 10.1016/j.jsha.2014.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 06/02/2014] [Accepted: 06/26/2014] [Indexed: 12/19/2022] Open
Abstract
The Brugada syndrome (BrS) is a malignant, genetically-determined, arrhythmic syndrome manifesting as syncope or sudden cardiac death (SCD) in individuals with structurally normal hearts. The diagnosis of the BrS is mainly based on the presence of a spontaneous or Na + channel blocker induced characteristic, electrocardiographic (ECG) pattern (type 1 or coved Brugada ECG pattern) typically seen in leads V1 and V2 recorded from the 4th to 2nd intercostal (i.c.) spaces. This pattern needs to be distinguished from similar ECG changes due to other causes (Brugada ECG phenocopies). This review focuses mainly on the ECG-based methods for diagnosis and arrhythmia risk assessment in the BrS. Presently, the main unresolved clinical problem is the identification of those patients at high risk of SCD who need implantable cardioverter-defibrillator (ICD), which is the only therapy with proven efficacy. Current guidelines recommend ICD implantation only in patients with spontaneous type 1 ECG pattern, and either history of aborted cardiac arrest or documented sustained VT (class I), or syncope of arrhythmic origin (class IIa) because they are at high risk of recurrent arrhythmic events (up to 10% or more annually for those with aborted cardiac arrest). The majority of BrS patients are asymptomatic when diagnosed and considered to have low risk (around 0.5% annually) and therefore not indicated for ICD. The majority of SCD victims in the BrS, however, had no symptoms prior to the fatal event and therefore were not protected with an ICD. While some ECG markers such as QRS fragmentation, infero-lateral early repolarisation, and abnormal late potentials on signal-averaged ECG are known to be linked to increased arrhythmic risk, they are not sufficiently sensitive or specific. Potential novel ECG-based strategies for risk stratification are discussed based on computerised methods for depolarisation and repolarisation analysis, a composite approach targeting several major components of ventricular arrhythmogenesis, and the collection of large digital ECG databases in genotyped BrS patients and their relatives.
Collapse
Key Words
- AP, action potential
- ARI, activation-recovery intervals
- BrS, Brugada syndrome
- Brugada syndrome
- ECG, electrocardiogram
- EPS, electrophysiology study
- Electrocardiogram
- Genetic arrhythmic syndromes
- ICD, implantable cardioverter-defibrillator
- IHD, ischaemic heart disease
- LBBB, left bundle branch block
- MAP, monophasic action potential
- MI, myocardial infarction
- PCA, principal component analysis
- RVOT, right ventricular outflow tract
- Risk stratification
- SAECG, signal-averaged electrocardiogram
- SCD, sudden cardiac death
- SNP, single-nucleotide polymorphism
- Sudden cardiac death
- VF, ventricular fibrillation
- VT, ventricular tachycardia
- WT, wavelet transform
Collapse
Affiliation(s)
- Abdulrahman Naseef
- Center for Health Studies, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
- Cardiac and Vascular Sciences Research Centre, St. George’s University of London, London, United Kingdom
| | - Elijah R. Behr
- Cardiac and Vascular Sciences Research Centre, St. George’s University of London, London, United Kingdom
| | - Velislav N. Batchvarov
- Cardiac and Vascular Sciences Research Centre, St. George’s University of London, London, United Kingdom
| |
Collapse
|
16
|
Cerrato N, Giustetto C, Gribaudo E, Richiardi E, Barbonaglia L, Scrocco C, Zema D, Gaita F. Prevalence of type 1 brugada electrocardiographic pattern evaluated by twelve-lead twenty-four-hour holter monitoring. Am J Cardiol 2015; 115:52-6. [PMID: 25456872 DOI: 10.1016/j.amjcard.2014.10.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 10/05/2014] [Accepted: 10/05/2014] [Indexed: 11/19/2022]
Abstract
Patients with drug-induced type 1 Brugada electrocardiograms (BrECGs) are considered to have good prognosis. Spontaneous type 1 is, instead, considered a risk factor; however, it is probably underestimated because of the BrECG fluctuations. The aim of this study was to analyze, in a large population of patients with Br, the real prevalence of type 1 BrECG using 12-lead 24-hour Holter monitoring (12L-Holter) and its correlation with the time of the day. We recorded 303 12L-Holter in 251 patients. Seventy-five (30%) patients exhibited spontaneous type 1 BrECG at 12-lead ECG (group 1) and 176 (70%) had only drug-induced type 1 (group 2). Type 1 BrECG was defined as "persistent" (>85% of the recording), "intermittent" (<85%), or "absent." In group 1, 12% showed persistent type 1 at 12L-Holter, 57% intermittent type 1%, and 31% never had type 1; in group 2, none had persistent type 1, 20% had intermittent type 1%, and 80% never showed type 1. To evaluate the circadian fluctuations of BrECG, 4 periods in the day were considered. Type 1 BrECG was more frequent between 12-noon and 6 p.m. (52%, p <0.001). In conclusion, in patients with drug-induced type 1, spontaneous type 1 BrECG can be detected more frequently with 12L-Holter than with conventional follow-up with periodic ECGs and this has important implications in the risk stratification. 12L-Holter recording might avoid 20% of the pharmacological challenges with sodium channel blockers, which are not without risks, and should thus be considered as the first screening test, particularly in children or in presence of borderline diagnostic basal ECG.
Collapse
Affiliation(s)
- Natascia Cerrato
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Torino, Torino, Italy
| | - Carla Giustetto
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Torino, Torino, Italy.
| | - Elena Gribaudo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Torino, Torino, Italy
| | | | | | - Chiara Scrocco
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Torino, Torino, Italy
| | - Domenica Zema
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Torino, Torino, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Torino, Torino, Italy
| |
Collapse
|
17
|
Batchvarov VN. The Brugada Syndrome - Diagnosis, Clinical Implications and Risk Stratification. Eur Cardiol 2014; 9:82-87. [PMID: 30310491 PMCID: PMC6159405 DOI: 10.15420/ecr.2014.9.2.82] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/24/2014] [Indexed: 12/19/2022] Open
Abstract
The Brugada syndrome (BrS) is a hereditary arrhythmic syndrome manifesting as syncope or sudden cardiac death (SCD) in individuals without overt structural heart disease. Currently, its diagnosis is mainly based on the presence of a spontaneous or Na+-channel blocker induced so-called "type 1" Brugada electrocardiographic (ECG) pattern typically seen in leads V1 and V2 recorded from the 4th to 2nd intercostal spaces. Presently the main unresolved clinical problem in the BrS is the identification of patients at high risk of SCD who need implantable cardioverter-defibrillator (ICD). Current guidelines recommend ICD implantation only in patients with spontaneous type 1 ECG pattern and either history of aborted cardiac arrest or documented sustained ventricular tachycardia (class I) or syncope of arrhythmic origin (class IIa) because they are at high risk of recurrent arrhythmias. However, the majority of BrS patients are asymptomatic when diagnosed and have generally low risk (0.5 % annually or lower) and therefore are not indicated for ICD. Most of SCD victims in the BrS have had no symptoms prior to the fatal event and therefore were not protected with an ICD. Currently there are no reliable methods to identify these potential victims of SCD. Although some ECG markers such as QRS fragmentation and infero-lateral early repolarisation have been demonstrated to signify increased arrhythmic risk their value still needs to be confirmed in large prospective studies. Novel risk assessment strategies need to be developed based on computerised quantitative ECG analysis of large digital ECG databases in patients with BrS and their relatives, and combined assessment of the most important factors of ventricular arrhythmogenesis.
Collapse
Affiliation(s)
- Velislav N Batchvarov
- Cardiovascular and Cell Sciences Research Institute, St George's University of London, London, UK
| |
Collapse
|
18
|
Intermittent Brugada Syndrome Presenting with Syncope in an Adult Female. Case Rep Emerg Med 2014; 2014:742076. [PMID: 25371832 PMCID: PMC4211173 DOI: 10.1155/2014/742076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 09/30/2014] [Accepted: 09/30/2014] [Indexed: 11/23/2022] Open
Abstract
Background. Brugada syndrome accounts for 4–12% of all sudden deaths worldwide and at least 20% of sudden deaths in patients with structurally normal hearts. Case Report. A 48-year-old female presented to the emergency department after two witnessed syncopal episodes. While awaiting discharge had a third collapse followed by cardiac arrest with shockable rhythm. Initial electrocardiogram showed wide QRS complex with left axis deviation, ST-segment elevation of <1 mm in V1 and V2, and flattening of T waves in V1. The angiogram did not demonstrate obstructive coronary disease. The electrocardiogram obtained two days after these events showed a right bundle branch block with ST-segment elevation of >2 mm followed by a negative T wave with no isoelectric separation, suggestive of spontaneous intermittent Brugada type 1 pattern. Cardiac magnetic resonance imaging demonstrated neither structural heart disease nor abnormal myocardium. After placement of an implantable cardioverter defibrillator the patient was discharged. Why should an emergency physician be aware of this? Brugada syndrome is an infrequently encountered clinical entity which may have a fatal outcome. This syndrome primarily presents with syncope. It should be considered as a component of differential diagnosis in patients with family history of syncope and sudden cardiac death.
Collapse
|
19
|
Adler A, Topaz G, Heller K, Zeltser D, Ohayon T, Rozovski U, Halkin A, Rosso R, Ben-Shachar S, Antzelevitch C, Viskin S. Fever-induced Brugada pattern: how common is it and what does it mean? Heart Rhythm 2013; 10:1375-82. [PMID: 23872691 DOI: 10.1016/j.hrthm.2013.07.030] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND Fever is known to unmask the Brugada pattern on the electrocardiogram (ECG) and trigger ventricular arrhythmias in patients with Brugada syndrome. Genetic studies in selected cases with fever-induced Brugada pattern have identified disease-causing mutations. Thus, "fever-induced Brugada" is a recognized clinical entity. However, its prevalence has not been systematically evaluated. OBJECTIVE The purpose of this study was to assess the prevalence of Brugada pattern in consecutive patients with fever. METHODS ECGs of patients with fever admitted to the emergency department were evaluated for the presence of Brugada pattern and compared with ECGs of consecutive nonfebrile patients. RESULTS ECGs of 402 patients with fever and 909 without were evaluated. Type I Brugada pattern was 20 times more common in the febrile group than in the afebrile group (2% vs. 0.1%, respectively, P = .0001). All patients with fever-induced type I Brugada pattern were asymptomatic and remained so during 30 months of follow-up. CONCLUSION Type I Brugada pattern is definitively more common among patients with fever, suggesting that asymptomatic Brugada syndrome is more prevalent than previously estimated.
Collapse
Affiliation(s)
- Arnon Adler
- Department of Cardiology, Tel-Aviv Sourasky Medical Center and Sackler School of Medicine, Tel-Aviv University, Israel
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
|
21
|
Wada T, Morita H. Clinical outcome and risk stratification in Brugada syndrome. J Arrhythm 2013. [DOI: 10.1016/j.joa.2012.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
|
22
|
Fernando RR, Yilmaz M, Higgins JP. The changing electrocardiogram in Brugada syndrome. Int J Cardiol 2013; 163:e36-7. [DOI: 10.1016/j.ijcard.2012.08.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 08/31/2012] [Indexed: 11/16/2022]
|
23
|
Affiliation(s)
- Yuka Mizusawa
- Heart Failure Research Centre, Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | | |
Collapse
|
24
|
Tagawa M, Chinushi M, Nakamura Y, Ochiai Y, Sato A, Iijima K, Uchiyama H, Furushima H, Aizawa Y. Recurrence of ventricular fibrillation in a patient with non-type 1 Brugada electrocardiographic morphology. J Cardiol Cases 2012; 6:e17-e19. [DOI: 10.1016/j.jccase.2012.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 03/02/2012] [Accepted: 03/14/2012] [Indexed: 11/29/2022] Open
|
25
|
Stern S. The Year of 2011 in Electrocardiology. Ann Noninvasive Electrocardiol 2012; 17:170-5. [DOI: 10.1111/j.1542-474x.2012.00536.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
26
|
Identification of high-risk syncope related to ventricular fibrillation in patients with Brugada syndrome. Heart Rhythm 2011; 9:752-9. [PMID: 22123317 DOI: 10.1016/j.hrthm.2011.11.045] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND Syncope in patients with Brugada syndrome is usually associated with ventricular tachyarrhythmia, but some episodes of syncope can be related to autonomic disorders. OBJECTIVE The purpose of this study was to investigate the characteristics of syncope to differentiate high-risk syncope episodes from low-risk events in patients with Brugada syndrome. METHODS We studied 84 patients with type 1 electrocardiogram and syncope. Patients were divided into 2 groups: patients with prodrome (prodromal group; n = 41) and patients without prodrome (nonprodromal group; n = 43). RESULTS Ventricular fibrillation (VF) was documented at index event in 19 patients: 4 patients (21%) with documented VF experienced a prodrome prior to the onset of VF, whereas 15 patients (79%) did not have symptoms prior to documented VF (P <.01). Twenty-seven patients in the prodromal group and 7 patients in the nonprodromal group were considered to have syncope related to autonomic dysfunction. Syncope in other patients was defined as unexplained syncope. During the follow-up period (48 ± 48 months), recurrent syncope due to VF occurred in 13 patients among patients with only unexplained syncope and was more frequent in the nonprodromal group (n = 10) than in the prodromal group (n = 3; P = .044). In multivariate analysis, blurred vision (hazard ratio [HR] 0.20) and abnormal respiration (HR 2.18) and fragmented QRS (HR 2.39) were independently associated with the occurrence of VF. CONCLUSION Syncope with prodrome, especially blurred vision, suggests a benign etiology of syncope in patients with Brugada syndrome.
Collapse
|
27
|
Shu J, Yan GX. Instability of type 1 Brugada wave: A more sensitive ECG predictor of cardiac events? Heart Rhythm 2011; 8:1022-3. [DOI: 10.1016/j.hrthm.2011.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Indexed: 11/24/2022]
|