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Tonko JB, Lambiase PD. The proarrhythmogenic role of autonomics and emerging neuromodulation approaches to prevent sudden death in cardiac ion channelopathies. Cardiovasc Res 2024; 120:114-131. [PMID: 38195920 PMCID: PMC10936753 DOI: 10.1093/cvr/cvae009] [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: 09/18/2023] [Revised: 11/06/2023] [Accepted: 11/30/2023] [Indexed: 01/11/2024] Open
Abstract
Ventricular arrhythmias in cardiac channelopathies are linked to autonomic triggers, which are sub-optimally targeted in current management strategies. Improved molecular understanding of cardiac channelopathies and cellular autonomic signalling could refine autonomic therapies to target the specific signalling pathways relevant to the specific aetiologies as well as the central nervous system centres involved in the cardiac autonomic regulation. This review summarizes key anatomical and physiological aspects of the cardiac autonomic nervous system and its impact on ventricular arrhythmias in primary inherited arrhythmia syndromes. Proarrhythmogenic autonomic effects and potential therapeutic targets in defined conditions including the Brugada syndrome, early repolarization syndrome, long QT syndrome, and catecholaminergic polymorphic ventricular tachycardia will be examined. Pharmacological and interventional neuromodulation options for these cardiac channelopathies are discussed. Promising new targets for cardiac neuromodulation include inhibitory and excitatory G-protein coupled receptors, neuropeptides, chemorepellents/attractants as well as the vagal and sympathetic nuclei in the central nervous system. Novel therapeutic strategies utilizing invasive and non-invasive deep brain/brain stem stimulation as well as the rapidly growing field of chemo-, opto-, or sonogenetics allowing cell-specific targeting to reduce ventricular arrhythmias are presented.
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Affiliation(s)
- Johanna B Tonko
- Institute of Cardiovascular Science, University College London, 5 University Street, London WC1E 6JF, London, UK
| | - Pier D Lambiase
- Institute of Cardiovascular Science, University College London, 5 University Street, London WC1E 6JF, London, UK
- Department for Cardiology, Bart’s Heart Centre, West Smithfield EC1A 7BE, London, UK
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2
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Badura K, Buławska D, Dąbek B, Witkowska A, Lisińska W, Radzioch E, Skwira S, Młynarska E, Rysz J, Franczyk B. Primary Electrical Heart Disease-Principles of Pathophysiology and Genetics. Int J Mol Sci 2024; 25:1826. [PMID: 38339103 PMCID: PMC10855675 DOI: 10.3390/ijms25031826] [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: 12/29/2023] [Revised: 01/27/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
Primary electrical heart diseases, often considered channelopathies, are inherited genetic abnormalities of cardiomyocyte electrical behavior carrying the risk of malignant arrhythmias leading to sudden cardiac death (SCD). Approximately 54% of sudden, unexpected deaths in individuals under the age of 35 do not exhibit signs of structural heart disease during autopsy, suggesting the potential significance of channelopathies in this group of age. Channelopathies constitute a highly heterogenous group comprising various diseases such as long QT syndrome (LQTS), short QT syndrome (SQTS), idiopathic ventricular fibrillation (IVF), Brugada syndrome (BrS), catecholaminergic polymorphic ventricular tachycardia (CPVT), and early repolarization syndromes (ERS). Although new advances in the diagnostic process of channelopathies have been made, the link between a disease and sudden cardiac death remains not fully explained. Evolving data in electrophysiology and genetic testing suggest previously described diseases as complex with multiple underlying genes and a high variety of factors associated with SCD in channelopathies. This review summarizes available, well-established information about channelopathy pathogenesis, genetic basics, and molecular aspects relative to principles of the pathophysiology of arrhythmia. In addition, general information about diagnostic approaches and management is presented. Analyzing principles of channelopathies and their underlying causes improves the understanding of genetic and molecular basics that may assist general research and improve SCD prevention.
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Affiliation(s)
- Krzysztof Badura
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland (S.S.)
| | - Dominika Buławska
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland (S.S.)
| | - Bartłomiej Dąbek
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland (S.S.)
| | - Alicja Witkowska
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland (S.S.)
| | - Wiktoria Lisińska
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland (S.S.)
| | - Ewa Radzioch
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland (S.S.)
| | - Sylwia Skwira
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland (S.S.)
| | - Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland (S.S.)
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, Ul. Zeromskiego 113, 90-549 Lodz, Poland (S.S.)
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Kataoka N, Imamura T, Kinugawa K. Letter by Kataoka et al Regarding Article, "Long-Term Outcomes of Brugada Substrate Ablation: A Report From BRAVO (Brugada Ablation of VF Substrate Ongoing Multicenter Registry)". Circulation 2023; 148:1914. [PMID: 38048394 DOI: 10.1161/circulationaha.123.065320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Affiliation(s)
- Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Japan
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Miles C, Boukens BJ, Scrocco C, Wilde AA, Nademanee K, Haissaguerre M, Coronel R, Behr ER. Subepicardial Cardiomyopathy: A Disease Underlying J-Wave Syndromes and Idiopathic Ventricular Fibrillation. Circulation 2023; 147:1622-1633. [PMID: 37216437 PMCID: PMC11073566 DOI: 10.1161/circulationaha.122.061924] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 03/27/2023] [Indexed: 05/24/2023]
Abstract
Brugada syndrome (BrS), early repolarization syndrome (ERS), and idiopathic ventricular fibrillation (iVF) have long been considered primary electrical disorders associated with malignant ventricular arrhythmia and sudden cardiac death. However, recent studies have revealed the presence of subtle microstructural abnormalities of the extracellular matrix in some cases of BrS, ERS, and iVF, particularly within right ventricular subepicardial myocardium. Substrate-based ablation within this region has been shown to ameliorate the electrocardiographic phenotype and to reduce arrhythmia frequency in BrS. Patients with ERS and iVF may also exhibit low-voltage and fractionated electrograms in the ventricular subepicardial myocardium, which can be treated with ablation. A significant proportion of patients with BrS and ERS, as well as some iVF survivors, harbor pathogenic variants in the voltage-gated sodium channel gene, SCN5A, but the majority of genetic susceptibility of these disorders is likely to be polygenic. Here, we postulate that BrS, ERS, and iVF may form part of a spectrum of subtle subepicardial cardiomyopathy. We propose that impaired sodium current, along with genetic and environmental susceptibility, precipitates a reduction in epicardial conduction reserve, facilitating current-to-load mismatch at sites of structural discontinuity, giving rise to electrocardiographic changes and the arrhythmogenic substrate.
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Affiliation(s)
- Chris Miles
- Cardiovascular Clinical Academic Group, St. George’s University Hospitals’ NHS Foundation Trust and Molecular and Clinical Sciences Institute, St. George’s, University of London, UK (C.M., C.S., E.R.B.)
| | - Bastiaan J. Boukens
- Department of Medical Biology, University of Amsterdam, the Netherlands (B.J.B.)
- University of Maastricht, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands (B.J.B.)
| | - Chiara Scrocco
- Cardiovascular Clinical Academic Group, St. George’s University Hospitals’ NHS Foundation Trust and Molecular and Clinical Sciences Institute, St. George’s, University of London, UK (C.M., C.S., E.R.B.)
| | - Arthur A.M. Wilde
- Amsterdam UMC, University of Amsterdam, Department of Cardiology, the Netherlands (A.A.M.W.)
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, the Netherlands (A.A.M.W.)
- European Reference Network for rare, low-prevalence, and complex diseases of the heart: ERN GUARD-Heart (A.A.M.W., M.H.)
| | - Koonlawee Nademanee
- Center of Excellence in Arrhythmia Research Chulalongkorn University, Department of Medicine, Chulalongkorn University, Thailand (K.N.)
- Pacific Rim Electrophysiology Research Institute, Bumrungrad Hospital, Bangkok, Thailand (K.N.)
| | - Michel Haissaguerre
- European Reference Network for rare, low-prevalence, and complex diseases of the heart: ERN GUARD-Heart (A.A.M.W., M.H.)
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France (M.H.)
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, France (M.H.)
| | - Ruben Coronel
- Department of Experimental Cardiology, Amsterdam University Medical Centers, Cardiovascular Science, the Netherlands (R.C.)
| | - Elijah R. Behr
- Cardiovascular Clinical Academic Group, St. George’s University Hospitals’ NHS Foundation Trust and Molecular and Clinical Sciences Institute, St. George’s, University of London, UK (C.M., C.S., E.R.B.)
- Mayo Clinic Healthcare, London, UK (E.R.B.)
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Fukuda T, Shinohara T, Yonezu K, Mitarai K, Hirota K, Kondo H, Fukui A, Akioka H, Teshima Y, Yufu K, Nakagawa M, Takahashi N. Vagal response is involved in the occurrence of ventricular fibrillation in patients with early repolarization syndrome. Heart Rhythm 2023; 20:879-885. [PMID: 36870380 DOI: 10.1016/j.hrthm.2023.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/31/2023] [Accepted: 02/26/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Patients with early repolarization syndrome (ERS) and Brugada syndrome (BruS) have comparable clinical symptoms. In both conditions, ventricular fibrillation (VF) is experienced often near midnight or in the early morning hours when the parasympathetic tone is augmented. However, differences between ERS and BruS regarding the risk of VF occurrence have recently been reported. The role of vagal activity remains especially unclear. OBJECTIVE The goal of this study was to determine the relationship between VF occurrence and autonomic nervous activity in patients with ERS and BruS. METHODS We enrolled 50 patients with ERS (n = 16) and BruS (n = 34) who received an implantable cardioverter-defibrillator. Of these, 20 patients (5 ERS and 15 BruS) experienced VF recurrence (recurrent VF group). We investigated baroreflex sensitivity (BaReS) with the phenylephrine method and heart rate variability using Holter electrocardiography in all patients to estimate autonomic nervous function. RESULTS In both patients with ERS and BruS, there was no significant difference in heart rate variability between the recurrent VF and nonrecurrent VF groups. However, in patients with ERS, BaReS was significantly higher in the recurrent VF group than in the nonrecurrent VF group (P = .03); this difference was not evident in patients with BruS. High BaReS was independently associated with VF recurrence in patients with ERS according to Cox proportional hazards regression analyses (hazard ratio 1.52; 95% confidence interval 1.031-3.061; P = .032). CONCLUSION Our findings suggest that in patients with ERS, an exaggerated vagal response, as represented by increased BaReS indices, may be involved in the risk of VF occurrence.
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Affiliation(s)
- Tomoko Fukuda
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan.
| | - Keisuke Yonezu
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
| | - Kazuki Mitarai
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
| | - Kei Hirota
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
| | - Hidekazu Kondo
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
| | - Akira Fukui
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
| | - Hidefumi Akioka
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
| | - Yasushi Teshima
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
| | - Kunio Yufu
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
| | - Mikiko Nakagawa
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Oita, Japan
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Cardiac Morphofunctional Characteristics of Individuals with Early Repolarization Pattern: A Literature Review. J Cardiovasc Dev Dis 2022; 10:jcdd10010004. [PMID: 36661899 PMCID: PMC9861558 DOI: 10.3390/jcdd10010004] [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] [Received: 12/03/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
The early repolarization pattern (ERP) is an electrocardiographic phenomenon characterized by the appearance of a distinct J-wave or J-point elevation at the terminal part of the QRS complex. ERP is associated with an increased risk of ventricular arrhythmias in susceptible individuals. The cardiac morphofunctional parameters in subjects with ERP have been characterized mainly by imaging techniques, which suggests that certain changes could be identified in the background of the electrical pathomechanism: however, in this regard, current data are often contradictory or insufficiently detailed. For clarification, a more comprehensive cardiac imaging evaluation of a large patient population is necessary. This review summarizes and analyses the data from the literature related to cardiac morphofunctional characteristics in individuals with ERP.
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Takada Y, Kusume T, Terasawa M, Yazaki Y, Satomi K. A case of short-coupled variant of Torsade de Pointes with bystander early repolarization in inferior leads. J Cardiol Cases 2022; 27:148-151. [PMID: 37012917 PMCID: PMC10066414 DOI: 10.1016/j.jccase.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/23/2022] [Accepted: 11/30/2022] [Indexed: 12/29/2022] Open
Abstract
The presence of J waves in cases of ventricular fibrillation (VF) is known to be a risk for sudden cardiac death. Recently, the effectiveness of radiofrequency catheter ablation (RFCA) for early repolarization syndrome (ERS) has been reported.The patient is a 30-year-old male with elevated J waves of 0.1 mV in the inferior leads, who had previously developed VF and undergone implantable cardioverter defibrillator (ICD) implantation. Because the VF from short coupled premature ventricular contraction (PVC) was presented, the RFCA of the triggered PVC was attempted. But it was unsuccessful due to no inducibility of the triggered PVC. After that, despite anti-arrythmia drug treatment, appropriate ICD shock for VF was observed. Although we decided to do a second ablation and evaluated epicardial arrhythmia substrate, no specific findings of early repolarization syndrome were found in the electrophysiological study. Finally, we considered that the cause of VF was short-coupled variant of Torsade de Pointes, and PVC ablation was performed. VF has not occurred since. We consider that this is a rare case to evaluate the epicardial arrhythmogenic substrate of J wave. Learning objective Ablation of the epicardial arrhythmogenic substrate in patients with early repolarization syndrome (ERS) has been shown to be effective, but the relationship between abnormal epicardial potentials and the pathophysiology is unclear. In this case, J-wave and epicardial delayed potentials were not considered to represent obvious arrhythmogenic substrates. Ablation of the triggered premature ventricular contraction may be effective in ERS without apparent abnormal potentials.
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8
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Krahn AD, Tfelt-Hansen J, Tadros R, Steinberg C, Semsarian C, Han HC. Latent Causes of Sudden Cardiac Arrest. JACC Clin Electrophysiol 2022; 8:806-821. [PMID: 35738861 DOI: 10.1016/j.jacep.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/09/2021] [Accepted: 12/29/2021] [Indexed: 11/30/2022]
Abstract
Inherited arrhythmia syndromes are a common cause of apparently unexplained cardiac arrest or sudden cardiac death. These include long QT syndrome and Brugada syndrome, with a well-recognized phenotype in most patients with sufficiently severe disease to lead to cardiac arrest. Less common and typically less apparent conditions that may not be readily evident include catecholaminergic polymorphic ventricular tachycardia, short QT syndrome and early repolarization syndrome. In cardiac arrest patients whose extensive testing does not reveal an underlying etiology, a diagnosis of idiopathic ventricular fibrillation or short-coupled ventricular fibrillation is assigned. This review summarizes our current understanding of the less common inherited arrhythmia syndromes and provides clinicians with a practical approach to diagnosis and management.
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Affiliation(s)
- Andrew D Krahn
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Jacob Tfelt-Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rafik Tadros
- Cardiovascular Genetics Center, Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Québec, Canada
| | - Christian Steinberg
- Institut universitaire de cardiologie et pneumologie de Québec (IUCPQ-UL), Laval University, Inherited Arrhythmia Services, Départment of Cardiology and Cardiac Surgery, Québec, Canada
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Hui-Chen Han
- Center for Cardiovascular Innovation, Heart Rhythm Services, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada; Victorian Heart Institute, Monash University, Clayton, Victoria, Australia
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9
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Yamaguchi Y, Sakamoto T, Hata Y, Nishida N, Mizumaki K. Recurrent ventricular fibrillation in a patient with inferolateral early repolarization and higher testosterone level. HeartRhythm Case Rep 2022; 8:370-373. [PMID: 35607334 PMCID: PMC9123328 DOI: 10.1016/j.hrcr.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Yukiko Hata
- Department of Legal Medicine, Faculty of Medicine, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Sugitani, Japan
| | - Naoki Nishida
- Department of Legal Medicine, Faculty of Medicine, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Sugitani, Japan
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Zhang ZH, Barajas-Martínez H, Xia H, Li B, Capra JA, Clatot J, Chen GX, Chen X, Yang B, Jiang H, Tse G, Aizawa Y, Gollob MH, Scheinman M, Antzelevitch C, Hu D. Distinct Features of Probands With Early Repolarization and Brugada Syndromes Carrying SCN5A Pathogenic Variants. J Am Coll Cardiol 2021; 78:1603-1617. [PMID: 34649698 DOI: 10.1016/j.jacc.2021.08.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Two major forms of inherited J-wave syndrome (JWS) are recognized: early repolarization syndrome (ERS) and Brugada syndrome (BrS). OBJECTIVES This study sought to assess the distinct features between patients with ERS and BrS carrying pathogenic variants in SCN5A. METHODS Clinical evaluation and next-generation sequencing were performed in 262 probands with BrS and 104 with ERS. Nav1.5 and Kv4.3 channels were studied with the use of patch-clamp techniques. A computational model was used to investigate the protein structure. RESULTS The SCN5A+ yield in ERS was significantly lower than in BrS (9.62% vs 22.90%; P = 0.004). Patients diagnosed with ERS displayed shorter QRS and QTc than patients with BrS. More than 2 pathogenic SCN5A variants were found in 5 probands. These patients displayed longer PR intervals and QRS duration and experienced more major arrhythmia events (MAE) compared with those carrying only a single pathogenic variant. SCN5A-L1412F, detected in a fever-induced ERS patient, led to total loss of function, destabilized the Nav1.5 structure, and showed a dominant-negative effect, which was accentuated during a febrile state. ERS-related SCN5A-G452C did not alter the inward sodium current (INa) when SCN5A was expressed alone, but when coexpressed with KCND3 it reduced peak INa by 44.52% and increased the transient outward potassium current (Ito) by 106.81%. CONCLUSIONS These findings point to SCN5A as a major susceptibility gene in ERS as much as it is in BrS, whereas the lower SCN5A+ ratio in ERS indicates the difference in underlying electrophysiology. These findings also identify the first case of fever-induced ERS and demonstrate a critical role of Ito in JWS and a higher risk for MAE in JWS probands carrying multiple pathogenic variants in SCN5A.
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Affiliation(s)
- Zhong-He Zhang
- Department of Cardiology and Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, Hubei, China; Hubei Key Laboratory of Cardiology, Wuhan, Hubei, China
| | - Hector Barajas-Martínez
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA; Lankenau Heart Institute, Wynnewood, Pennsylvania, USA; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Hao Xia
- Department of Cardiology and Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, Hubei, China; Hubei Key Laboratory of Cardiology, Wuhan, Hubei, China
| | - Bian Li
- Department of Biological Sciences, Center for Structural Biology, Vanderbilt University, Nashville, Tennessee, USA; Vanderbilt Genetics Institute, Vanderbilt University, Nashville, Tennessee, USA
| | - John A Capra
- Bakar Computational Health Sciences Institute, University of California, San Francisco, California, USA
| | - Jerome Clatot
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gan-Xiao Chen
- Department of Cardiology and Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, Hubei, China; Hubei Key Laboratory of Cardiology, Wuhan, Hubei, China
| | - Xiu Chen
- Department of Cardiology and Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, Hubei, China; Hubei Key Laboratory of Cardiology, Wuhan, Hubei, China
| | - Bo Yang
- Department of Cardiology and Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, Hubei, China; Hubei Key Laboratory of Cardiology, Wuhan, Hubei, China
| | - Hong Jiang
- Department of Cardiology and Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, Hubei, China; Hubei Key Laboratory of Cardiology, Wuhan, Hubei, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China; Kent and Medway Medical School, Canterbury, Kent, United Kingdom
| | - Yoshiyasu Aizawa
- Department of Cardiovascular Medicine, School of Medicine 4-3, International University of Health and Welfare, Kozunomori, Narita, Chiba, Japan
| | - Michael H Gollob
- Department of Physiology and Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - Melvin Scheinman
- Department of Cardiac Electrophysiology, University of California, San Francisco, California, USA
| | - Charles Antzelevitch
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA; Lankenau Heart Institute, Wynnewood, Pennsylvania, USA; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dan Hu
- Department of Cardiology and Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, Hubei, China; Hubei Key Laboratory of Cardiology, Wuhan, Hubei, China.
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11
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Antzelevitch C, Di Diego JM. J wave syndromes: What's new? Trends Cardiovasc Med 2021; 32:350-363. [PMID: 34256120 PMCID: PMC8743304 DOI: 10.1016/j.tcm.2021.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 07/03/2021] [Accepted: 07/04/2021] [Indexed: 12/19/2022]
Abstract
Among the inherited ion channelopathies associated with potentially life-threatening ventricular arrhythmia syndromes in nominally structurally normal hearts are the J wave syndromes, which include the Brugada (BrS) and early repolarization (ERS) syndromes. These ion channelopathies are responsible for sudden cardiac death (SCD), most often in young adults in the third and fourth decade of life. Our principal goal in this review is to briefly outline the clinical characteristics, as well as the molecular, ionic, cellular, and genetic mechanisms underlying these primary electrical diseases that have challenged the cardiology community over the past two decades. In addition, we discuss our recently developed whole-heart experimental model of BrS, providing compelling evidence in support of the repolarization hypothesis for the BrS phenotype as well as novel findings demonstrating that voltage-gated sodium and transient outward current channels can modulate each other's function via trafficking and gating mechanisms with implications for improved understanding of the genetics of both cardiac and neuronal syndromes.
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Affiliation(s)
- Charles Antzelevitch
- Distinguished Professor Emeritus and Executive Director, Cardiovascular Research, Lankenau Institute for Medical Research, Wynnewood, PA 19096, USA; Lankenau Institute for Medical Research, Wynnwoddm PA USA; Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia PA, USA.
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12
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Stiles MK, Wilde AAM, Abrams DJ, Ackerman MJ, Albert CM, Behr ER, Chugh SS, Cornel MC, Gardner K, Ingles J, James CA, Juang JMJ, Kääb S, Kaufman ES, Krahn AD, Lubitz SA, MacLeod H, Morillo CA, Nademanee K, Probst V, Saarel EV, Sacilotto L, Semsarian C, Sheppard MN, Shimizu W, Skinner JR, Tfelt-Hansen J, Wang DW. 2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families. J Arrhythm 2021; 37:481-534. [PMID: 34141003 PMCID: PMC8207384 DOI: 10.1002/joa3.12449] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 12/26/2022] Open
Abstract
This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.
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Affiliation(s)
- Martin K Stiles
- Waikato Clinical School Faculty of Medicine and Health Science The University of Auckland Hamilton New Zealand
| | - Arthur A M Wilde
- Heart Center Department of Clinical and Experimental Cardiology Amsterdam University Medical Center University of Amsterdam Amsterdam the Netherlands
| | | | | | | | - Elijah R Behr
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute St George's University of London, and St George's University Hospitals NHS Foundation Trust London UK
| | | | - Martina C Cornel
- Amsterdam University Medical Center Vrije Universiteit Amsterdam Clinical Genetics Amsterdam Public Health Research Institute Amsterdam the Netherlands
| | | | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute The University of Sydney Sydney Australia
| | | | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology Department of Internal Medicine National Taiwan University Hospital and National Taiwan University College of Medicine Taipei Taiwan
| | - Stefan Kääb
- Department of Medicine I University Hospital LMU Munich Munich Germany
| | | | | | | | - Heather MacLeod
- Data Coordinating Center for the Sudden Death in the Young Case Registry Okemos MI USA
| | | | - Koonlawee Nademanee
- Chulalongkorn University Faculty of Medicine, and Pacific Rim Electrophysiology Research Institute at Bumrungrad Hospital Bangkok Thailand
| | | | - Elizabeth V Saarel
- Cleveland Clinic Lerner College of Cardiology at Case Western Reserve University Cleveland OH USA
- St Luke's Medical Center Boise ID USA
| | - Luciana Sacilotto
- Heart Institute University of São Paulo Medical School São Paulo Brazil
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute The University of Sydney Sydney Australia
| | - Mary N Sheppard
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute St George's University of London, and St George's University Hospitals NHS Foundation Trust London UK
| | - Wataru Shimizu
- Department of Cardiovascular Medicine Nippon Medical School Tokyo Japan
| | | | - Jacob Tfelt-Hansen
- Department of Forensic Medicine Faculty of Medical Sciences Rigshospitalet Copenhagen Denmark
| | - Dao Wu Wang
- The First Affiliated Hospital of Nanjing Medical University Nanjing China
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13
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Stiles MK, Wilde AAM, Abrams DJ, Ackerman MJ, Albert CM, Behr ER, Chugh SS, Cornel MC, Gardner K, Ingles J, James CA, Jimmy Juang JM, Kääb S, Kaufman ES, Krahn AD, Lubitz SA, MacLeod H, Morillo CA, Nademanee K, Probst V, Saarel EV, Sacilotto L, Semsarian C, Sheppard MN, Shimizu W, Skinner JR, Tfelt-Hansen J, Wang DW. 2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families. Heart Rhythm 2021; 18:e1-e50. [PMID: 33091602 PMCID: PMC8194370 DOI: 10.1016/j.hrthm.2020.10.010] [Citation(s) in RCA: 140] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 12/13/2022]
Abstract
This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.
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Affiliation(s)
- Martin K Stiles
- Waikato Clinical School, Faculty of Medicine and Health Science, The University of Auckland, Hamilton, New Zealand
| | - Arthur A M Wilde
- Amsterdam University Medical Center, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam, the Netherlands
| | | | | | | | - Elijah R Behr
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sumeet S Chugh
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Martina C Cornel
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Clinical Genetics, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | | | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Stefan Kääb
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | | | - Andrew D Krahn
- The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Heather MacLeod
- Data Coordinating Center for the Sudden Death in the Young Case Registry, Okemos, Michigan, USA
| | | | - Koonlawee Nademanee
- Chulalongkorn University, Faculty of Medicine, and Pacific Rim Electrophysiology Research Institute at Bumrungrad Hospital, Bangkok, Thailand
| | | | - Elizabeth V Saarel
- Cleveland Clinic Lerner College of Cardiology at Case Western Reserve University, Cleveland, Ohio, and St Luke's Medical Center, Boise, Idaho, USA
| | - Luciana Sacilotto
- Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Mary N Sheppard
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Jonathan R Skinner
- Cardiac Inherited Disease Group, Starship Hospital, Auckland, New Zealand
| | - Jacob Tfelt-Hansen
- Department of Forensic Medicine, Faculty of Medical Sciences, Rigshospitalet, Copenhagen, Denmark
| | - Dao Wu Wang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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14
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Major Z, Kirschner R, Medvegy N, Kiss K, Török GM, Pavlik G, Simonyi G, Komka Z, Medvegy M. The importance of ST elevation in V 2-4 ECG leads in athletes. Physiol Int 2019. [PMID: 31847533 DOI: 10.1556/2060.106.2019.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Early repolarization in the anterior ECG leads (ERV2-4) is considered to be a sign of right ventricular (RV) remodeling, but its etiology and importance are unclear. METHODS A total of 243 top-level endurance-trained athletes (ETA; 183 men and 60 women, weekly training hours: 15-20) and 120 leisure-time athletes (LTA; 71 men and 49 women, weekly training hours: 5-6) were investigated. The ERV2-4 sign was evaluated concerning type of sport, gender, transthoracic echocardiographic parameters, and ECG changes, which can indicate elevated RV systolic pressure [left atrium enlargement (LAE), right atrium enlargement (RAE), RV conduction defect (RVcd)]. RESULTS Stroke volume and left ventricular mass were higher in ETAs vs. LTAs in both genders (p < 0.01). Prevalence of the ERV2-4 sign was significantly higher in men than in women [p = 0.000, odds ratio (OR) = 36.4] and in ETAs than in LTAs (p = 0.000). The highest ERV2-4 prevalence appeared in the most highly trained triathlonists and canoe and kayak paddlers (OR = 13.8 and 5.2, respectively). Within the ETA group, the post-exercise LAE, RAE, and RVcd changes developed more frequently in cases with than without ERV2-4 (LAE: men: p < 0.05, females: p < 0.005; RAE: men: p < 0.05, females: p < 0.005; RVcd: N.S.). These post-exercise appearing LAE, RAE, and RVcd are associated with the ERV2-4 sign (OR = 4.0, 3.7, and 3.8, respectively). CONCLUSIONS According to these results, ERV2-4 develops mainly in male ETAs due to long-lasting and repeated endurance training. The ERV2-4 sign indicates RV's adaptation to maintain higher compensatory pulmonary pressure and flow during exercise but its danger regarding malignant arrhythmias is unclear.
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Affiliation(s)
- Zs Major
- Institute of Physical Education and Sport Sciences, University of Nyíregyháza, Nyíregyháza, Hungary
| | - R Kirschner
- Department of Cardiology, Flór Ferenc Hospital of Pest County, Kistarcsa, Hungary
| | - N Medvegy
- Department of Marketing, KRKA Hungary Ltd., Budapest, Hungary
| | - K Kiss
- Department of Cardiology, Flór Ferenc Hospital of Pest County, Kistarcsa, Hungary
| | - G M Török
- Department of Cardiology, Flór Ferenc Hospital of Pest County, Kistarcsa, Hungary
| | - G Pavlik
- Department of Health Sciences and Sports Medicine, University of Physical Education, Budapest, Hungary
| | - G Simonyi
- Metabolic Center, St. Imre University Teaching Hospital, Budapest, Hungary
| | - Zs Komka
- The Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - M Medvegy
- Department of Cardiology, Flór Ferenc Hospital of Pest County, Kistarcsa, Hungary
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15
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Yoon N, Patocskai B, Antzelevitch C. Epicardial Substrate as a Target for Radiofrequency Ablation in an Experimental Model of Early Repolarization Syndrome. Circ Arrhythm Electrophysiol 2019; 11:e006511. [PMID: 30354293 DOI: 10.1161/circep.118.006511] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early repolarization syndrome (ERS) is an inherited cardiac arrhythmia syndrome associated with sudden cardiac death. Approaches to therapy are currently very limited. This study probes the mechanisms underlying the electrocardiographic and arrhythmic manifestation of experimental models of ERS and of the ameliorative effect of radiofrequency ablation. METHODS Action potentials, bipolar electrograms, and transmural pseudo-ECGs were simultaneously recorded from coronary-perfused canine left ventricular wedge preparations (n=11). The Ito agonist NS5806 (7-10 μmol/L), calcium channel blocker verapamil (3 μmol/L), and acetylcholine (1-3 μmol/L) were used to pharmacologically mimic the effects of genetic defects associated with ERS. RESULTS The provocative agents induced prominent J waves in the ECG secondary to accentuation of the action potential notch in epicardium but not endocardium. Bipolar recordings displayed low-voltage fractionated potentials in epicardium because of temporal and spatial variability in appearance of the action potential dome. Concealed phase 2 reentry developed when action potential dome was lost at some epicardial sites but not others, appearing in the bipolar electrogram as discrete high-frequency spikes. Successful propagation of the phase 2 reentrant beat precipitated ventricular tachycardia/ventricular fibrillation. Radiofrequency ablation of the epicardium destroyed the cells displaying abnormal repolarization and thus suppressed the J waves and the development of ventricular tachycardia/ventricular fibrillation in 6/6 preparations. CONCLUSIONS Our findings suggest that low-voltage fractionated electrical activity and high-frequency late potentials recorded from the epicardial surface of the left ventricle can identify regions of abnormal repolarization responsible for ventricular tachycardia/ventricular fibrillation in ERS and that radiofrequency ablation of these regions in left ventricular epicardium can suppress ventricular tachycardia/ventricular fibrillation by destroying regions of ER.
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Affiliation(s)
- Namsik Yoon
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea (N.Y.).,Masonic Medical Research Laboratory, Utica, NY (N.Y., B.P., C.A.)
| | - Bence Patocskai
- Institute of Physiology and Pathophysiology, Faculty of Medicine, University of Heidelberg, Germany (B.P.).,DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg-Mannheim, Germany (B.P.).,Masonic Medical Research Laboratory, Utica, NY (N.Y., B.P., C.A.)
| | - Charles Antzelevitch
- Masonic Medical Research Laboratory, Utica, NY (N.Y., B.P., C.A.).,Cardiovascular Research Program, Lankenau Institute for Medical Research, Philadelphia, PA (C.A.).,Lankenau Heart Institute, Philadelphia, PA (C.A.).,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (C.A.)
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16
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Inferolateral J-wave syndromes: A reflection of abnormal repolarization, depolarization, or both? Heart Rhythm 2019; 16:791-792. [DOI: 10.1016/j.hrthm.2018.11.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Indexed: 01/23/2023]
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17
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Nagayama T, Nagase S, Kamakura T, Wada M, Ishibashi K, Inoue YY, Miyamoto K, Noda T, Aiba T, Takaki H, Sugimachi M, Shimizu W, Noguchi T, Yasuda S, Kamakura S, Kusano K. Clinical and Electrocardiographic Differences in Brugada Syndrome With Spontaneous or Drug-Induced Type 1 Electrocardiogram. Circ J 2019; 83:532-539. [DOI: 10.1253/circj.cj-18-0643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Tomomi Nagayama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
- Department of Cardiovascular Medicine, Fukuoka City Hospital
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tsukasa Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mitsuru Wada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yuko Y. Inoue
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroshi Takaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masaru Sugimachi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Shiro Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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18
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Belenkov YN, Snezhitskiy VA, Gizatulina TP, Shpak NV, Kuznetsov VA, Martyanova LU, Ardashev AV. [Not Available]. KARDIOLOGIIA 2018; 58:41-52. [PMID: 30625077 DOI: 10.18087/cardio.2018.11.10196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 11/24/2018] [Indexed: 06/09/2023]
Abstract
This review includes main positions of the revision of diagnostic criteria of "J-wave syndromes in the J-Wave Syndromes Expert Consensus Conference Report: Emerging Concepts and Gaps in Knowledge" (2016). The article, systematized according to the sections of the above-mentioned document, outlines the questions of terminology, new criteria for diagnosis of the Brugada syndrome (BrS) and early repolarization syndrome (ERS). The section devoted to ERS on the issues of new terminology and standardization of measurements, is supplemented with material from the Consensus Paper - The Early Repolarization Pattern (2015). The article also presents the issues of differential diagnosis in BrS, presents modulating factors, defines acquired Brugada-pattern and Brugada phenocopies. The similarities and differences between BrS and ERS are presented in a comparative aspect.
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Affiliation(s)
- Yu N Belenkov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University).
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19
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Casado Arroyo R, Sieira J, Kubala M, Latcu DG, Maeda S, Brugada P. Electrophysiological Basis for Early Repolarization Syndrome. Front Cardiovasc Med 2018; 5:161. [PMID: 30460246 PMCID: PMC6232947 DOI: 10.3389/fcvm.2018.00161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 10/19/2018] [Indexed: 12/16/2022] Open
Abstract
During last centuries, Early Repolarization pattern has been interpreted as an ECG manifestation not linked to serious cardiovascular events. This view has been challenged on the basis of sporadic clinical observations that linked the J-wave with ventricular arrhythmias and sudden cardiac death. The particular role of this characteristic pattern in initiating ventricular fibrillation has been sustained by clinical descriptions of a marked and consistent J-wave elevation preceding the onset of the ventricular arrhythmia. Until now, Early Repolarization syndrome patients have been evaluated using ECG and theorizing different interpretations of the findings. Nonetheless, ECG analysis is not able to reveal all depolarization and repolarization properties and the explanation for this clinical events. Recent studies have characterized the epicardial substrate in these patients on the basis of high-resolution data, in an effort to provide insights into the substrate properties that support arrhythmogenicity in these patients. An overview for the current evidence supporting different theories explaining Early Repolarization Syndrome is provided in this review. Finally, future developments in the field directed toward individualized treatment strategies are examined.
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Affiliation(s)
- Rubén Casado Arroyo
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Juan Sieira
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Maciej Kubala
- Department of Cardiology, Centre Hospitalier Universitaire, Amiens, France
| | | | - Shigo Maeda
- Advanced Arrhythmia Research, Tokyo Medical and Dental University, Tokyo, Japan
| | - Pedro Brugada
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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20
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Hayashi K, Kohno R, Akamatsu N, Benditt DG, Abe H. Abnormal repolarization: A common electrocardiographic finding in patients with epilepsy. J Cardiovasc Electrophysiol 2018; 30:109-115. [PMID: 30230121 DOI: 10.1111/jce.13746] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 08/29/2018] [Accepted: 09/12/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recently, certain forms of early repolarization (ER) on electrocardiograms (ECGs) have been considered a possible marker of increased sudden cardiac death risk. The frequency, characteristics, and clinical follow-up with which these forms of ER are present in epilepsy patients, and whether or not abnormal ER contributes to sudden unexplained death in epilepsy patients (SUDEP) is unknown. METHODS AND RESULTS The amplitude of J peak and ST-segment morphology after ER on 12-lead ECGs were assessed in 354 epilepsy patients (age, 33 ± 16 years; 54% men) and 140 age- and sex-matched control subjects (age, 31 ± 12 years; 50% men). Abnormal ER prevalence (J-wave amplitude ≥0.1 mV) was greater in epilepsy patients (19.8%) compared with controls (8.6%; P = 0.002) in inferior ECG leads but not in lateral leads ( P = 0.40). ER with a horizontal or descending ST segment was also more prevalent in epilepsy patients ( P < 0.001). After introducing antiepileptic drugs in 36 epilepsy patients, there were no significant ER changes. Similarly, in 64 epilepsy patients with seizure suppression, ER comparison before and after seizure control revealed no significant changes. Male gender was the only significant predictor of abnormal ER in epilepsy patients ( P = 0.03). During a median follow-up of 7 years, SUDEP occurred in two patients, one with abnormal ER. CONCLUSIONS Abnormal ER may be more prevalent in epilepsy patients than in controls and is not altered by antiepileptic drugs or achievement of epilepsy suppression. The relation of abnormal ER to SUDEP remains in need of further study.
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Affiliation(s)
- Katsuhide Hayashi
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Ritsuko Kohno
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Kitakyushu, Japan.,Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
| | - Naoki Akamatsu
- Department of Medical Technology and Sciences, International University of Health and Welfare, School of Medical Sciences, Fukuoka, Japan
| | - David G Benditt
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
| | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Kitakyushu, Japan
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21
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Di Diego JM, Antzelevitch C. J wave syndromes as a cause of malignant cardiac arrhythmias. Pacing Clin Electrophysiol 2018; 41:684-699. [PMID: 29870068 PMCID: PMC6281786 DOI: 10.1111/pace.13408] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 05/05/2018] [Indexed: 12/19/2022]
Abstract
The J wave syndromes, including the Brugada (BrS) and early repolarization (ERS) syndromes, are characterized by the manifestation of prominent J waves in the electrocardiogram appearing as an ST segment elevation and the development of life-threatening cardiac arrhythmias. BrS and ERS differ with respect to the magnitude and lead location of abnormal J waves and are thought to represent a continuous spectrum of phenotypic expression termed J wave syndromes. Despite over 25 years of intensive research, risk stratification and the approach to therapy of these two inherited cardiac arrhythmia syndromes are still rapidly evolving. Our objective in this review is to provide an integrated synopsis of the clinical characteristics, risk stratifiers, as well as the molecular, ionic, cellular, and genetic mechanisms underlying these two syndromes that have captured the interest and attention of the cardiology community over the past two decades.
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Affiliation(s)
| | - Charles Antzelevitch
- Lankenau Institute for Medical Research, Wynnewood PA
- Lankenau Heart Institute, Wynnewood, PA
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia PA
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22
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Lee A, Kohler H, Wright D, Haqqani HM. Epicardial Brugada syndrome ablation unmasking inferior J waves. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1308-1312. [DOI: 10.1111/pace.13095] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 03/17/2017] [Accepted: 04/12/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Adam Lee
- Department of Cardiology; The Prince Charles Hospital; Brisbane Australia
- School of Medicine; The University of Queensland; Brisbane Australia
| | | | - Daniel Wright
- Department of Cardiology; The Prince Charles Hospital; Brisbane Australia
| | - Haris M. Haqqani
- Department of Cardiology; The Prince Charles Hospital; Brisbane Australia
- School of Medicine; The University of Queensland; Brisbane Australia
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23
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Liu X, Shen Y, Xie J, Bao H, Cao Q, Wan R, Xu X, Zhou H, Huang L, Xu Z, Zhu W, Hu J, Cheng X, Hong K. A mutation in the CACNA1C gene leads to early repolarization syndrome with incomplete penetrance: A Chinese family study. PLoS One 2017; 12:e0177532. [PMID: 28493952 PMCID: PMC5426766 DOI: 10.1371/journal.pone.0177532] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 04/28/2017] [Indexed: 01/06/2023] Open
Abstract
Background Early repolarization syndrome (ERS) may be a near-Mendelian or an oligogenic disease; however, no direct evidence has been provided to support this theory. Methods and results We described a large Chinese family with nocturnal sudden cardiac death induced by ERS in most of the young male adults. One missense mutation (p.Q1916R) was found in the major subunit of the L-type calcium channel gene CACNA1C by the direct sequencing of candidate genes. A concomitant gain-of-function variant in the sodium channel gene SCN5A (p.R1193Q) was found to rescue the phenotype of the female CACNA1C-Q1916R mutation carriers, which led to the incomplete penetrance. The functional studies, via the exogenous expression approach, revealed that the CACNA1C-Q1916R mutation led to a decreasing L-type calcium current and the protein expression defect. The decreased calcium current produced by the mutant channel was improved by isoproterenol but exacerbated by testosterone. The effects of CACNA1C-Q1916R mutation and testosterone on cellular electrophysiology were further confirmed by the human ventricular action potential simulation. Conclusions Our results demonstrated that the loss-of-function CACNA1C-Q1916R mutation contributed to ERS-related sudden cardiac death, and the phenotypic incomplete penetrance was modified by the SCN5A-R1193Q variant and sex. These findings suggest that phenotypes of ERS are modified by multiple genetic factors, which supports the theory that ERS may be an oligogenic disease.
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Affiliation(s)
- Xin Liu
- Department of Cardiovascular medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yang Shen
- Jiangxi Province Key Laboratory of Molecular Medicine, Nanchang, China
| | - Jinyan Xie
- Jiangxi Province Key Laboratory of Molecular Medicine, Nanchang, China
| | - Huihui Bao
- Department of Cardiovascular medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qing Cao
- Jiangxi Province Key Laboratory of Molecular Medicine, Nanchang, China
| | - Rong Wan
- Jiangxi Province Key Laboratory of Molecular Medicine, Nanchang, China
| | - Xiaoming Xu
- Department of Forensic Medicine, Medical College of Nanchang University, Nanchang, China
| | - Hui Zhou
- Department of Cardiovascular medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Lin Huang
- Department of Cardiovascular medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhenyan Xu
- Department of Cardiovascular medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wengen Zhu
- Department of Cardiovascular medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jinzhu Hu
- Department of Cardiovascular medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaoshu Cheng
- Department of Cardiovascular medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Kui Hong
- Department of Cardiovascular medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Province Key Laboratory of Molecular Medicine, Nanchang, China
- * E-mail:
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Antzelevitch C, Yan GX, Ackerman MJ, Borggrefe M, Corrado D, Guo J, Gussak I, Hasdemir C, Horie M, Huikuri H, Ma C, Morita H, Nam GB, Sacher F, Shimizu W, Viskin S, Wilde AA. J-Wave syndromes expert consensus conference report: Emerging concepts and gaps in knowledge. Europace 2017; 19:665-694. [PMID: 28431071 PMCID: PMC5834028 DOI: 10.1093/europace/euw235] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
| | - Gan-Xin Yan
- Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Michael J. Ackerman
- Departments of Cardiovascular Diseases, Pediatrics, and Molecular Pharmacology & Experimental Therapeutics, Divisions of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester,Minnesota
| | - Martin Borggrefe
- 1st Department of Medicine–Cardiology, University Medical Centre Mannheim, and DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Jihong Guo
- Division of Cardiology, Peking University of People's Hospital, Beijing, China
| | - Ihor Gussak
- Rutgers University, New Brunswick, New Jersey
| | - Can Hasdemir
- Department of Cardiology, Ege University School of Medicine, Izmir, Turkey
| | - Minoru Horie
- Shiga University of Medical Sciences, Ohtsu, Shiga, Japan
| | - Heikki Huikuri
- Research Unit of Internal Medicine, Medical Research Center, Oulu University Hospital, and University of Oulu, Oulu, Finland
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Gi-Byoung Nam
- Heart Institute, Asan Medical Center, and Department of Internal Medicine, University of Ulsan College of Medicine Seoul, Seoul, Korea
| | - Frederic Sacher
- Bordeaux University Hospital, LIRYC Institute/INSERM 1045, Bordeaux, France
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Sami Viskin
- Tel-Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arthur A.M. Wilde
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands and Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders, Jeddah, Kingdom of Saudi Arabia
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25
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Konishi S, Minamiguchi H, Okuyama Y, Sakata Y. Sodium channel blockade unmasked Brugada electrocardiographic pattern in a patient with complete right bundle branch block and early repolarization in the lateral leads. Clin Case Rep 2016; 4:1061-1064. [PMID: 27830074 PMCID: PMC5093164 DOI: 10.1002/ccr3.636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 05/24/2016] [Accepted: 06/16/2016] [Indexed: 11/26/2022] Open
Abstract
Early repolarization syndrome (ERS) and Brugada syndrome (BrS) share many electrocardiographic and clinical features, and recently have been collectively grouped as J wave syndrome. However, the effects of sodium channel blockers on the J waves differ greatly between ERS and BrS.
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Affiliation(s)
- Shozo Konishi
- Department of Cardiovascular Medicine Osaka Graduate School of Medicine Suita Japan
| | - Hitoshi Minamiguchi
- Department of Cardiovascular Medicine Osaka Graduate School of Medicine Suita Japan
| | - Yuji Okuyama
- Department of Cardiovascular Medicine Osaka Graduate School of Medicine Suita Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine Osaka Graduate School of Medicine Suita Japan
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26
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Antzelevitch C, Yan GX, Ackerman MJ, Borggrefe M, Corrado D, Guo J, Gussak I, Hasdemir C, Horie M, Huikuri H, Ma C, Morita H, Nam GB, Sacher F, Shimizu W, Viskin S, Wilde AA. J-Wave syndromes expert consensus conference report: Emerging concepts and gaps in knowledge. J Arrhythm 2016; 32:315-339. [PMID: 27761155 PMCID: PMC5063270 DOI: 10.1016/j.joa.2016.07.002] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
| | - Gan-Xin Yan
- Lankenau Medical Center, Wynnewood, PA, United States
| | - Michael J. Ackerman
- Departments of Cardiovascular Diseases, Pediatrics, and Molecular Pharmacology & Experimental Therapeutics, Divisions of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN, United States
| | - Martin Borggrefe
- 1st Department of Medicine–Cardiology, University Medical Centre Mannheim, and DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Jihong Guo
- Division of Cardiology, Peking University of People׳s Hospital, Beijing, China
| | - Ihor Gussak
- Rutgers University, New Brunswick, NJ, United States
| | - Can Hasdemir
- Department of Cardiology, Ege University School of Medicine, Izmir, Turkey
| | - Minoru Horie
- Shiga University of Medical Sciences, Ohtsu, Shiga, Japan
| | - Heikki Huikuri
- Research Unit of Internal Medicine, Medical Research Center, Oulu University Hospital, and University of Oulu, Oulu, Finland
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Gi-Byoung Nam
- Heart Institute, Asian Medical Center, and Department of Internal Medicine, University of Ulsan College of Medicine Seoul, Seoul, South Korea
| | - Frederic Sacher
- Bordeaux University Hospital, LIRYC Institute/INSERM 1045, Bordeaux, France
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Sami Viskin
- Tel-Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arthur A.M. Wilde
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, University of Amsterdam, The Netherlands
- Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders, Jeddah, Saudi Arabia
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27
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Antzelevitch C, Yan GX, Ackerman MJ, Borggrefe M, Corrado D, Guo J, Gussak I, Hasdemir C, Horie M, Huikuri H, Ma C, Morita H, Nam GB, Sacher F, Shimizu W, Viskin S, Wilde AAM. J-Wave syndromes expert consensus conference report: Emerging concepts and gaps in knowledge. Heart Rhythm 2016; 13:e295-324. [PMID: 27423412 PMCID: PMC5035208 DOI: 10.1016/j.hrthm.2016.05.024] [Citation(s) in RCA: 222] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Indexed: 12/16/2022]
Affiliation(s)
| | - Gan-Xin Yan
- Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Michael J Ackerman
- Departments of Cardiovascular Diseases, Pediatrics, and Molecular Pharmacology & Experimental Therapeutics, Divisions of Heart Rhythm Services and Pediatric Cardiology, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester,Minnesota
| | - Martin Borggrefe
- 1st Department of Medicine-Cardiology, University Medical Centre Mannheim, and DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Domenico Corrado
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Jihong Guo
- Division of Cardiology, Peking University of People's Hospital, Beijing, China
| | - Ihor Gussak
- Rutgers University, New Brunswick, New Jersey
| | - Can Hasdemir
- Department of Cardiology, Ege University School of Medicine, Izmir, Turkey
| | - Minoru Horie
- Shiga University of Medical Sciences, Ohtsu, Shiga, Japan
| | - Heikki Huikuri
- Research Unit of Internal Medicine, Medical Research Center, Oulu University Hospital, and University of Oulu, Oulu, Finland
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Okayama, Japan
| | - Gi-Byoung Nam
- Heart Institute, Asan Medical Center, and Department of Internal Medicine, University of Ulsan College of Medicine Seoul, Seoul, Korea
| | - Frederic Sacher
- Bordeaux University Hospital, LIRYC Institute/INSERM 1045, Bordeaux, France
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Sami Viskin
- Tel-Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arthur A M Wilde
- Heart Center, Department of Clinical and Experimental Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands and Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders, Jeddah, Kingdom of Saudi Arabia
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28
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To the Editor—Flecainide and ventricular fibrillation in patients with early repolarization syndrome. Heart Rhythm 2016; 13:e291. [DOI: 10.1016/j.hrthm.2016.06.017] [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: 05/19/2016] [Indexed: 11/22/2022]
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Ahn J, Kim YH. Reply to the Editor— Effect of Flecainide on Suppression of Ventricular Fibrillation in a Patient With Early Repolarization Syndrome. Heart Rhythm 2016; 13:e291. [DOI: 10.1016/j.hrthm.2016.06.016] [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: 06/09/2016] [Indexed: 11/16/2022]
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Meijborg VMF, Potse M, Conrath CE, Belterman CNW, De Bakker JMT, Coronel R. Reduced Sodium Current in the Lateral Ventricular Wall Induces Inferolateral J-Waves. Front Physiol 2016; 7:365. [PMID: 27616994 PMCID: PMC5000556 DOI: 10.3389/fphys.2016.00365] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/09/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND J-waves in inferolateral leads are associated with a higher risk for idiopathic ventricular fibrillation. We aimed to test potential mechanisms (depolarization or repolarization dependent) responsible for inferolateral J-waves. We hypothesized that inferolateral J-waves can be caused by regional delayed activation of myocardium that is activated late during normal conditions. METHODS Computer simulations were performed to evaluate how J-point elevation is influenced by reducing sodium current conductivity (GNa), increasing transient outward current conductivity (Gto), or cellular uncoupling in three predefined ventricular regions (lateral, anterior, or septal). Two pig hearts were Langendorff-perfused with selective perfusion with a sodium channel blocker of lateral or anterior/septal regions. Volume-conducted pseudo-electrocardiograms (ECG) were recorded to detect the presence of J-waves. Epicardial unipolar electrograms were simultaneously recorded to obtain activation times (AT). RESULTS Simulation data showed that conduction slowing, caused by reduced sodium current, in lateral, but not in other regions induced inferolateral J-waves. An increase in transient outward potassium current or cellular uncoupling in the lateral zone elicited slight J-point elevations which did not meet J-wave criteria. Additional conduction slowing in the entire heart attenuated J-waves and J-point elevations on the ECG, because of masking by the QRS. Experimental data confirmed that conduction slowing attributed to sodium channel blockade in the left lateral but not in the anterior/septal ventricular region induced inferolateral J-waves. J-waves coincided with the delayed activation. CONCLUSION Reduced sodium current in the left lateral ventricular myocardium can cause inferolateral J-waves on the ECG.
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Affiliation(s)
- Veronique M F Meijborg
- Department of Clinical and Experimental Cardiology, Academic Medical CenterAmsterdam, Netherlands; Interuniversity Cardiology Institute of the NetherlandsUtrecht, Netherlands
| | - Mark Potse
- Electrophysiology and Heart Modeling Institute LIRYC, Université de BordeauxBordeaux, France; Modélisation et calculs pour l'électrophysiologie cardiaque (Carmen) team, Inria Bordeaux Sud-OuestBordeaux, France; Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italianaLugano, Switzerland
| | - Chantal E Conrath
- Department of Clinical and Experimental Cardiology, Academic Medical Center Amsterdam, Netherlands
| | - Charly N W Belterman
- Department of Clinical and Experimental Cardiology, Academic Medical CenterAmsterdam, Netherlands; Electrophysiology and Heart Modeling Institute LIRYC, Université de BordeauxBordeaux, France
| | - Jacques M T De Bakker
- Department of Clinical and Experimental Cardiology, Academic Medical CenterAmsterdam, Netherlands; Interuniversity Cardiology Institute of the NetherlandsUtrecht, Netherlands; Department of Medical Physiology, University of UtrechtUtrecht, Netherlands
| | - Ruben Coronel
- Department of Clinical and Experimental Cardiology, Academic Medical CenterAmsterdam, Netherlands; Electrophysiology and Heart Modeling Institute LIRYC, Université de BordeauxBordeaux, France
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Mercer BN, Begg GA, Page SP, Bennett CP, Tayebjee MH, Mahida S. Early Repolarization Syndrome; Mechanistic Theories and Clinical Correlates. Front Physiol 2016; 7:266. [PMID: 27445855 PMCID: PMC4927622 DOI: 10.3389/fphys.2016.00266] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/15/2016] [Indexed: 12/20/2022] Open
Abstract
The early repolarization (ER) pattern on the 12-lead electrocardiogram is characterized by J point elevation in the inferior and/or lateral leads. The ER pattern is associated with an increased risk of ventricular arrhythmias and sudden cardiac death (SCD). Based on studies in animal models and genetic studies, it has been proposed that J point elevation in ER is a manifestation of augmented dispersion of repolarization which creates a substrate for ventricular arrhythmia. A competing theory regarding early repolarization syndrome (ERS) proposes that the syndrome arises as a consequence of abnormal depolarization. In recent years, multiple clinical studies have described the characteristics of ER patients with VF in more detail. The majority of these studies have provided evidence to support basic science observations. However, not all clinical observations correlate with basic science findings. This review will provide an overview of basic science and genetic research in ER and correlate basic science evidence with the clinical phenotype.
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Affiliation(s)
- Ben N. Mercer
- West Yorkshire Arrhythmia Service, Leeds General InfirmaryLeeds, UK
| | - Gordon A. Begg
- West Yorkshire Arrhythmia Service, Leeds General InfirmaryLeeds, UK
| | - Stephen P. Page
- West Yorkshire Arrhythmia Service, Leeds General InfirmaryLeeds, UK
- Regional Inherited Cardiovascular Conditions Service, Leeds General InfirmaryLeeds, UK
| | | | | | - Saagar Mahida
- West Yorkshire Arrhythmia Service, Leeds General InfirmaryLeeds, UK
- Regional Inherited Cardiovascular Conditions Service, Leeds General InfirmaryLeeds, UK
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32
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Ishizue N, Niwano S, Saito M, Fukaya H, Nakamura H, Igarashi T, Fujiishi T, Yoshizawa T, Oikawa J, Satoh A, Kishihara J, Murakami M, Niwano H, Miyaoka H, Ako J. Polytherapy with sodium channel-blocking antiepileptic drugs is associated with arrhythmogenic ST-T abnormality in patients with epilepsy. Seizure 2016; 40:81-7. [PMID: 27371909 DOI: 10.1016/j.seizure.2016.06.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 05/31/2016] [Accepted: 06/07/2016] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Recent reports have documented the appearance of Brugada-type ST elevation in cases of overdose of antiepileptic drugs (AEDs). However, little is known about changes on electrocardiographs (ECGs) during AED use at therapeutic doses. AEDs may cause Brugada-type ST elevation or J-wave-like intraventricular conduction delays through an ion channel-blocking effect. In the present study, we sought to elucidate ECG abnormalities in patients on AED therapy. METHODS The study population consisted of 120 consecutive patients with epilepsy who continued to take AEDs and had ECGs recorded during these therapies. Their clinical background and ECGs were retrospectively analyzed. Brugada-type ST elevation was classified according to the consensus report on Brugada syndrome. A J-wave-like ECG abnormality was defined as the appearance of notching or slurring of the QRS complex (>0.1mV) in the inferior/lateral leads. RESULTS Of the 120 patients, 15 (12.5%) exhibited Brugada-type ST elevation and 35 (29.2%) showed a J-wave-like ECG abnormality. Polytherapy with sodium channel-blocking AEDs (e.g., carbamazepine, phenytoin, lamotrigine) was more frequently observed in patients with Brugada-type ST elevation (p=0.048). However, the serum concentrations of these medicines did not differ between patients with and without ECG abnormalities (carbamazepine: 7.9±4.1 vs. 7.2±5.9μg/dL; phenytoin: 12.7±4.1 vs. 15.5±9.5μg/dL, NS). CONCLUSION ST-T abnormalities were frequently seen in patients using AEDs. The presence of Brugada-type ST elevation was associated with polytherapy with sodium channel-blocking AEDs.
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Affiliation(s)
- Naruya Ishizue
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan.
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masanori Saito
- Department of Psychiatry, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hidehira Fukaya
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hironori Nakamura
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tazuru Igarashi
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tamami Fujiishi
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tomoharu Yoshizawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Jun Oikawa
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Akira Satoh
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masami Murakami
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hiroe Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Hitoshi Miyaoka
- Department of Psychiatry, Kitasato University School of Medicine, Sagamihara, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
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Mellor G, Nelson CP, Robb C, Raju H, Wijeyeratne Y, Hengstenberg C, Reinhard W, Papadakis M, Sharma S, Samani NJ, Behr ER. The Prevalence and Significance of the Early Repolarization Pattern in Sudden Arrhythmic Death Syndrome Families. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.116.003960. [DOI: 10.1161/circep.116.003960] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/03/2016] [Indexed: 12/21/2022]
Affiliation(s)
- Greg Mellor
- From the Cardiac Research Centre, St. George’s University of London, London, United Kingdom (G.M., C.R., H.R., Y.W., M.P., S.S., E.R.B.); Department of Cardiovascular Sciences, University of Leicester & National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom (C.P.N., N.J.S.); Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, München, Germany (C.H., W.R.); and Deutsches Zentrum für
| | - Christopher P. Nelson
- From the Cardiac Research Centre, St. George’s University of London, London, United Kingdom (G.M., C.R., H.R., Y.W., M.P., S.S., E.R.B.); Department of Cardiovascular Sciences, University of Leicester & National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom (C.P.N., N.J.S.); Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, München, Germany (C.H., W.R.); and Deutsches Zentrum für
| | - Claire Robb
- From the Cardiac Research Centre, St. George’s University of London, London, United Kingdom (G.M., C.R., H.R., Y.W., M.P., S.S., E.R.B.); Department of Cardiovascular Sciences, University of Leicester & National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom (C.P.N., N.J.S.); Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, München, Germany (C.H., W.R.); and Deutsches Zentrum für
| | - Hariharan Raju
- From the Cardiac Research Centre, St. George’s University of London, London, United Kingdom (G.M., C.R., H.R., Y.W., M.P., S.S., E.R.B.); Department of Cardiovascular Sciences, University of Leicester & National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom (C.P.N., N.J.S.); Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, München, Germany (C.H., W.R.); and Deutsches Zentrum für
| | - Yanushi Wijeyeratne
- From the Cardiac Research Centre, St. George’s University of London, London, United Kingdom (G.M., C.R., H.R., Y.W., M.P., S.S., E.R.B.); Department of Cardiovascular Sciences, University of Leicester & National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom (C.P.N., N.J.S.); Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, München, Germany (C.H., W.R.); and Deutsches Zentrum für
| | - Christian Hengstenberg
- From the Cardiac Research Centre, St. George’s University of London, London, United Kingdom (G.M., C.R., H.R., Y.W., M.P., S.S., E.R.B.); Department of Cardiovascular Sciences, University of Leicester & National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom (C.P.N., N.J.S.); Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, München, Germany (C.H., W.R.); and Deutsches Zentrum für
| | - Wibke Reinhard
- From the Cardiac Research Centre, St. George’s University of London, London, United Kingdom (G.M., C.R., H.R., Y.W., M.P., S.S., E.R.B.); Department of Cardiovascular Sciences, University of Leicester & National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom (C.P.N., N.J.S.); Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, München, Germany (C.H., W.R.); and Deutsches Zentrum für
| | - Michael Papadakis
- From the Cardiac Research Centre, St. George’s University of London, London, United Kingdom (G.M., C.R., H.R., Y.W., M.P., S.S., E.R.B.); Department of Cardiovascular Sciences, University of Leicester & National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom (C.P.N., N.J.S.); Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, München, Germany (C.H., W.R.); and Deutsches Zentrum für
| | - Sanjay Sharma
- From the Cardiac Research Centre, St. George’s University of London, London, United Kingdom (G.M., C.R., H.R., Y.W., M.P., S.S., E.R.B.); Department of Cardiovascular Sciences, University of Leicester & National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom (C.P.N., N.J.S.); Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, München, Germany (C.H., W.R.); and Deutsches Zentrum für
| | - Nilesh J. Samani
- From the Cardiac Research Centre, St. George’s University of London, London, United Kingdom (G.M., C.R., H.R., Y.W., M.P., S.S., E.R.B.); Department of Cardiovascular Sciences, University of Leicester & National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom (C.P.N., N.J.S.); Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, München, Germany (C.H., W.R.); and Deutsches Zentrum für
| | - Elijah R. Behr
- From the Cardiac Research Centre, St. George’s University of London, London, United Kingdom (G.M., C.R., H.R., Y.W., M.P., S.S., E.R.B.); Department of Cardiovascular Sciences, University of Leicester & National Institute for Health Research Leicester Cardiovascular Biomedical Research Unit, Leicester, United Kingdom (C.P.N., N.J.S.); Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, München, Germany (C.H., W.R.); and Deutsches Zentrum für
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Hada Y, Nishizaki M, Yamawake N, Sakurada H, Hiraoka M. Appearance of J wave in the inferolateral leads and ventricular fibrillation provoked by mild hypothermia in a patient with Brugada syndrome. HeartRhythm Case Rep 2016; 2:407-411. [PMID: 28491722 PMCID: PMC5419947 DOI: 10.1016/j.hrcr.2016.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Yasuaki Hada
- Department of Cardiology, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | | | - Noriyoshi Yamawake
- Department of Cardiology, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Harumizu Sakurada
- Department of Cardiology, Tokyo Metropolitan Health and Medical Treatment Corporation, Ohkubo Hospital, Tokyo, Japan
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Wilde AAM. Challenging the unifying pathophysiological concept of J-wave syndromes. Heart Rhythm 2016; 13:1729-30. [PMID: 27132151 DOI: 10.1016/j.hrthm.2016.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Arthur A M Wilde
- Heart Centre, Department of Clinical and Experimental Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands,; (†)Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders, Jeddah, Kingdom of Saudi Arabia.
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Ahn J, Roh SY, Lee DI, Shim J, Choi JI, Kim YH. Effect of flecainide on suppression of ventricular fibrillation in a patient with early repolarization syndrome. Heart Rhythm 2016; 13:1724-8. [PMID: 27033341 DOI: 10.1016/j.hrthm.2016.03.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Indexed: 01/27/2023]
Affiliation(s)
- Jinhee Ahn
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Seung-Young Roh
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Dae-In Lee
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea.
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Maeda S, Takahashi Y, Nogami A, Yamauchi Y, Osaka Y, Shirai Y, Ihara K, Yokoyama Y, Suzuki M, Okishige K, Nishizaki M, Hirao K. Seasonal, weekly, and circadian distribution of ventricular fibrillation in patients with J-wave syndrome from the J-PREVENT registry. J Arrhythm 2015; 31:268-73. [PMID: 26550081 PMCID: PMC4600836 DOI: 10.1016/j.joa.2015.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 01/15/2015] [Accepted: 01/26/2015] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Ventricular fibrillation (VF) in Brugada syndrome (BrS) is known to occur more frequently during nighttime and from spring to early summer. In this study, we investigated whether early repolarization syndrome (ERS) has the same seasonal, weekly, and circadian distribution of VF events as BrS using data from the "J-wave associated with prior cardiac event" (J-PREVENT) registry. METHODS The study included 90 consecutive patients with BrS and 31 patients with ERS during a mean follow-up of 49±37 months. Follow-up data from implantable cardioverter-defibrillators were evaluated in all cases. RESULTS In patients with ERS, the circadian distribution of VF episodes differed among the four 6-h periods, with a significant peak from midnight to 6:00 am (p<0.01) similar to that observed in BrS patients. However, VF occurred more frequently on weekends in patients with ERS, whereas on weekdays in patients with BrS (p<0.01). The months of peak VF occurrence also differed between the groups, with the frequency of VF episodes at peak between December and March in ERS patients and between March and June in BrS patients. In ERS patients, VF events had an inverse correlation with air temperature (r=-0.726, p<0.01). CONCLUSIONS ERS and BrS patients show similar nighttime increases in the occurrence of VF, but different seasonal and weekly distributions, suggesting a pathophysiological difference between the two syndromes.
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Affiliation(s)
- Shingo Maeda
- Heart Rhythm Center, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | | | - Akihiko Nogami
- Department of Heart Rhythm Management, Yokohama Rosai Hospital, Yokohama, Japan
| | - Yasuteru Yamauchi
- Department of Cardiology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Yuki Osaka
- Department of Cardiology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Yasuhiro Shirai
- Heart Rhythm Center, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Kensuke Ihara
- Heart Rhythm Center, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Yasuhiro Yokoyama
- Heart Rhythm Center, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Makoto Suzuki
- Department of Cardiovascular Medicine, Kameda General Hospital, Kamogawa, Japan
| | - Kaoru Okishige
- Heart Center, Yokohama City Bay Red Cross Hospital, Yokohama, Japan
| | | | - Kenzo Hirao
- Heart Rhythm Center, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
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38
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Ali A, Butt N, Sheikh AS. Early repolarization syndrome: A cause of sudden cardiac death. World J Cardiol 2015; 7:466-75. [PMID: 26322186 PMCID: PMC4549780 DOI: 10.4330/wjc.v7.i8.466] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 05/18/2015] [Accepted: 06/01/2015] [Indexed: 02/06/2023] Open
Abstract
Early repolarization syndrome (ERS), demonstrated as J-point elevation on an electrocardiograph, was formerly thought to be a benign entity, but the recent studies have demonstrated that it can be linked to a considerable risk of life - threatening arrhythmias and sudden cardiac death (SCD). Early repolarization characteristics associated with SCD include high - amplitude J-point elevation, horizontal and/or downslopping ST segments, and inferior and/or lateral leads location. The prevalence of ERS varies between 3% and 24%, depending on age, sex and J-point elevation (0.05 mV vs 0.1 mV) being the main determinants. ERS patients are sporadic and they are at a higher risk of having recurrent cardiac events. Implantable cardioverter-defibrillator implantation and isoproterenol are the suggested therapies in this set of patients. On the other hand, asymptomatic patients with ERS are common and have a better prognosis. The risk stratification in asymptomatic patients with ERS still remains a grey area. This review provides an outline of the up-to-date evidence associated with ERS and the risk of life - threatening arrhythmias. Further prospective studies are required to elucidate the mechanisms of ventricular arrhythmogenesis in patients with ERS.
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Affiliation(s)
- Abdi Ali
- Abdi Ali, Nida Butt, Core Medical Trainees, Wrexham Maelor Hospital, Wrexham, Wales LL13 7TZ, United Kingdom
| | - Nida Butt
- Abdi Ali, Nida Butt, Core Medical Trainees, Wrexham Maelor Hospital, Wrexham, Wales LL13 7TZ, United Kingdom
| | - Azeem S Sheikh
- Abdi Ali, Nida Butt, Core Medical Trainees, Wrexham Maelor Hospital, Wrexham, Wales LL13 7TZ, United Kingdom
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Abstract
A prominent J wave is encountered in a number of life-threatening cardiac arrhythmia syndromes, including the Brugada syndrome and early repolarization syndromes. Brugada syndrome and early repolarization syndromes differ with respect to the magnitude and lead location of abnormal J waves and are thought to represent a continuous spectrum of phenotypic expression termed J-wave syndromes. Despite two decades of intensive research, risk stratification and the approach to therapy of these 2 inherited cardiac arrhythmia syndromes are still undergoing rapid evolution. Our objective in this review is to provide an integrated synopsis of the clinical characteristics, risk stratifiers, and molecular, ionic, cellular, and genetic mechanisms underlying these 2 fascinating syndromes that have captured the interest and attention of the cardiology community in recent years.
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Affiliation(s)
| | - Gan-Xin Yan
- Lankenau Institute for Medical Research and Lankenau Medical Center, Wynnewood, Pennsylvania; Jefferson Medical College, Philadelphia, Pennsylvania; The First Affiliated Hospital, Medical School of Xi'an Jiaotong University, Xi'an, China
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Hoogendijk MG, Coronel R. J-wave syndrome(s). Trends Cardiovasc Med 2014; 25:22-3. [PMID: 25454381 DOI: 10.1016/j.tcm.2014.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 09/26/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Mark G Hoogendijk
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, Nieuwegein 3435 CM, The Netherlands.
| | - Ruben Coronel
- Department of Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands
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Badri M, Patel A, Yan GX. Cellular and ionic basis of J-wave syndromes. Trends Cardiovasc Med 2014; 25:12-21. [PMID: 25446046 DOI: 10.1016/j.tcm.2014.09.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/11/2014] [Accepted: 09/13/2014] [Indexed: 01/11/2023]
Abstract
J-wave syndromes are disorders of ventricular repolarization characterized by prominent J waves on the ECG and have the potential to predispose affected individuals to lethal ventricular arrhythmias. These disorders share a common cellular mechanism with prominent Ito in ventricular epicardium. This current causes transmural dispersion of repolarization and the generation of phase 2 reentry, leading to short-coupled extrasystoles and VF. Several autonomic, chemical, and hormonal factors modulate Ito and are therefore vital in attenuating or increasing the arrhythmic potential of these syndromes. Future research should focus on evaluating the arrhythmogenic potential of patients with pathogenic genotypes and/or J waves and no history of VF.
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Affiliation(s)
- Marwan Badri
- Lankenau Medical Center and Lankenau Institute for Medical Research, Wynnewood, PA
| | - Aashay Patel
- Lankenau Medical Center and Lankenau Institute for Medical Research, Wynnewood, PA
| | - Gan-Xin Yan
- Lankenau Medical Center and Lankenau Institute for Medical Research, Wynnewood, PA; The First Teaching Hospital, Xi'An Jiaotong University, Xi'An, China; Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA.
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Kaneko Y, Horie M, Niwano S, Kusano KF, Takatsuki S, Kurita T, Mitsuhashi T, Nakajima T, Irie T, Hasegawa K, Noda T, Kamakura S, Aizawa Y, Yasuoka R, Torigoe K, Suzuki H, Ohe T, Shimizu A, Fukuda K, Kurabayashi M, Aizawa Y. Electrical storm in patients with brugada syndrome is associated with early repolarization. Circ Arrhythm Electrophysiol 2014; 7:1122-8. [PMID: 25221333 DOI: 10.1161/circep.114.001806] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Electrical storms (ESs) in patients with Brugada syndrome (BrS) are rare though potentially lethal. METHODS AND RESULTS We studied 22 men with BrS and ES, defined as ≥3 episodes/d of ventricular fibrillation (VF) and compared their characteristics with those of 110 age-matched, control men with BrS without ES. BrS was diagnosed by a spontaneous or drug-induced type 1 pattern on the ECG in the absence of structural heart disease. Early repolarization (ER) was diagnosed by J waves, ie, >0.1 mV notches or slurs of the terminal portion of the QRS complex. The BrS ECG pattern was provoked with pilsicainide. A spontaneous type I ECG pattern, J waves, and horizontal/descending ST elevation were found, respectively, in 77%, 36%, and 88% of patients with ES, versus 28% (P<0.0001), 9% (P=0.003), and 60% (P=0.06) of controls. The J-wave amplitude was significantly higher in patients with than without ES (P=0.03). VF occurred during undisturbed sinus rhythm in 14 of 19 patients (74%), and ES were controlled by isoproterenol administration. All patients with ES received an implantable cardioverter defibrillator and over a 6.0±5.4 years follow-up, the prognosis of patients with ES was significantly worse than that of patients without ES. Bepridil was effective in preventing VF in 6 patients. CONCLUSIONS A high prevalence of ER was found in a subgroup of patients with BrS associated with ES. ES appeared to be suppressed by isoproterenol or quinidine, whereas bepridil and quinidine were effective in the long-term prevention of VF in the highest-risk patients.
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Affiliation(s)
- Yoshiaki Kaneko
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.).
| | - Minoru Horie
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Shinichi Niwano
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Kengo F Kusano
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Seiji Takatsuki
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Takashi Kurita
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Takeshi Mitsuhashi
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Tadashi Nakajima
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Tadanobu Irie
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Kanae Hasegawa
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Takashi Noda
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Shiro Kamakura
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Yoshiyasu Aizawa
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Ryobun Yasuoka
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Katsumi Torigoe
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Hiroshi Suzuki
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Toru Ohe
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Akihiko Shimizu
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Keiichi Fukuda
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Masahiko Kurabayashi
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
| | - Yoshifusa Aizawa
- From the Department of Medicine and Biological Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan (Y.K., T.N., T.I., M.K.); Department of Cardiovascular and Respiratory Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan (M.H., K.H.); Department of Cardio-Angiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan (S.N.); Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (S.N.); (K.F.K., T.N., S.K.); Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (S.T., Yoshiyasu A., K.F.); Department of Medicine, Division of Cardiology, Faculty of Medicine, Kinki University, Osaka (T.K., R.Y.); Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan (T.M.); Department of Pediatrics, Nagaoka Red Cross Hospital, Nagaoka, Japan (K.T.); Department of Pediatrics, Niigata University School of Medicine, Niigata, Japan (H.S.); Research Division, The Sakakibara Heart Institute of Okayama, Okayama, Japan (T.O.); Faculty of Health Sciences, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan (A.S.); Department of Research and Development, Tachikawa Medical Center, Nagaoka, Niigata, Japan (Yoshifusa A.)
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Takahashi Y, Osaka Y, Nogami A, Nishizaki M, Okishige K, Suzuki M, Yamauchi Y, Ono Y, Suzuki K, Hirao K, Isobe M. Inducibility of ventricular arrhythmias in early repolarization syndrome and Brugada syndrome: From the J-wave associated with prior cardiac event (J-PREVENT) registry. J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Choudhuri I, Pinninti M, Marwali MR, Sra J, Akhtar M. Polymorphic ventricular tachycardia--part II: the channelopathies. Curr Probl Cardiol 2014; 38:503-48. [PMID: 24262155 DOI: 10.1016/j.cpcardiol.2013.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
In this article, we explore the clinical and cellular phenomena of primary electrical diseases of the heart, that is, conditions purely related to ion channel dysfunction and not structural heart disease or reversible acquired causes. This growing classification of conditions, once considered together as "idiopathic ventricular fibrillation," continues to evolve and segregate into diseases that are phenotypically, molecularly, and genetically unique.
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Koncz I, Gurabi Z, Patocskai B, Panama BK, Szél T, Hu D, Barajas-Martínez H, Antzelevitch C. Mechanisms underlying the development of the electrocardiographic and arrhythmic manifestations of early repolarization syndrome. J Mol Cell Cardiol 2013; 68:20-8. [PMID: 24378566 DOI: 10.1016/j.yjmcc.2013.12.012] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 10/25/2013] [Accepted: 12/13/2013] [Indexed: 12/14/2022]
Abstract
Early repolarization pattern in the ECG has been associated with increased risk for ventricular tachycardia/fibrillation (VT/VF), particularly when manifest in inferior leads. This study examines the mechanisms underlying VT/VF in early repolarization syndrome (ERS). Transmembrane action potentials (APs) were simultaneously recorded from 2 epicardial sites and 1 endocardial site of coronary-perfused canine left-ventricular (LV) wedge preparations, together with a pseudo-ECG. Transient outward current (Ito) was recorded from epicardial myocytes isolated from the inferior and lateral LV of the same heart. J wave area (pseudo-ECG), epicardial AP notch magnitude and index were larger in inferior vs. lateral wall preparations at baseline and after exposure to provocative agents (NS5806+verapamil+acetylcholine (ACh)). Ito density was greater in myocytes from inferior vs. lateral wall (18.4 ± 2.3pA/pF vs. 11.6 ± 2.0pA/pF; p<0.05). A combination of NS5806 (7 μM) and verapamil (3 μM) or pinacidil (4 μM), used to pharmacologically model the genetic defects responsible for ERS, resulted in prominent J-point and ST-segment elevation. ACh (3 μM), simulating increased vagal tone, precipitated phase-2-reentry-induced polymorphic VT/VF. Using identical protocols, inducibility of arrhythmias was 3-fold higher in inferior vs. lateral wedges. Quinidine (10 μM) or isoproterenol (1 μM) restored homogeneity and suppressed VT/VF. Our data support the hypothesis that 1) ERS is caused by a preferential accentuation of the AP notch in the LV epicardium; 2) this repolarization defect is accentuated by elevated vagal tone; 3) higher intrinsic levels of Ito account for the greater sensitivity of the inferior LV wall to development of VT/VF; and 4) quinidine and isoproterenol exert ameliorative effects by reversing the repolarization abnormality.
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Affiliation(s)
- István Koncz
- Department of Molecular Genetics, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Experimental Cardiology, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Pharmacology & Pharmacotherapy, University of Szeged, H-6720 Szeged, Dóm tér 12, Hungary
| | - Zsolt Gurabi
- Department of Molecular Genetics, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Experimental Cardiology, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Pharmacology & Pharmacotherapy, University of Szeged, H-6720 Szeged, Dóm tér 12, Hungary
| | - Bence Patocskai
- Department of Molecular Genetics, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Experimental Cardiology, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Pharmacology & Pharmacotherapy, University of Szeged, H-6720 Szeged, Dóm tér 12, Hungary
| | - Brian K Panama
- Department of Molecular Genetics, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Experimental Cardiology, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA
| | - Tamás Szél
- Department of Molecular Genetics, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Experimental Cardiology, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Pharmacology & Pharmacotherapy, University of Szeged, H-6720 Szeged, Dóm tér 12, Hungary
| | - Dan Hu
- Department of Molecular Genetics, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Experimental Cardiology, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA
| | - Hector Barajas-Martínez
- Department of Molecular Genetics, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Experimental Cardiology, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA
| | - Charles Antzelevitch
- Department of Molecular Genetics, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA; Department of Experimental Cardiology, Masonic Medical Research Laboratory, 2150 Bleecker St., Utica, NY 13501, USA.
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Abstract
An early repolarization (ER) pattern in the ECG, consisting of J point elevation, distinct J wave with or without ST segment elevation or slurring of the terminal part of the QRS, was long considered a benign electrocardiographic manifestation. Experimental studies a dozen years ago suggested that an ER is not always benign, but may be associated with malignant arrhythmias. Validation of this hypothesis derives from recent case-control and population-based studies showing that an ER pattern in inferior or infero-lateral leads is associated with increased risk for life-threatening arrhythmias, termed early repolarization syndrome (ERS). Because accentuated J waves characterize both Brugada syndrome (BrS) and ERS, these syndromes have been grouped under the heading of J wave syndromes. BrS and ERS appear to share common ECG characteristics, clinical outcomes, risk factors as well as a common arrhythmic platform related to amplification of Ito-mediated J waves. However, they differ with respect to the magnitude and lead location of abnormal J waves and can be considered to represent a continuous spectrum of phenotypic expression. Recent studies support the hypothesis that BrS and ERS are caused by a preferential accentuation of the AP notch in right or left ventricular epicardium, respectively, and that this repolarization defect is accentuated by cholinergic agonists. Quinidine, cilostazol and isoproterenol exert ameliorative effects by reversing these repolarization abnormalities. Identifying subjects truly at risk is the challenge ahead. Our goal here is to review the clinical and genetic aspects as well as the cellular and molecular mechanisms underlying the J wave syndromes.
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Significance of Non-Type 1 Anterior Early Repolarization in Patients With Inferolateral Early Repolarization Syndrome. J Am Coll Cardiol 2013; 62:1610-8. [DOI: 10.1016/j.jacc.2013.05.081] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 05/07/2013] [Indexed: 11/21/2022]
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Rezus C, Floria M, Moga VD, Sirbu O, Dima N, Ionescu SD, Ambarus V. Early repolarization syndrome: electrocardiographic signs and clinical implications. Ann Noninvasive Electrocardiol 2013; 19:15-22. [PMID: 24118137 DOI: 10.1111/anec.12113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Early repolarization syndrome (ERS) was previously considered as a benign variant, but it has recently emerged as a risk marker for idiopathic ventricular fibrillation (VF) and sudden death. As measured by electrocardiogram (ECG), early repolarization is characterized by an elevation of the J point and/or ST segment from the baseline by at least 0.1 mV in at least two adjoining leads. In particular, early repolarization detected by inferior ECG leads was found to be associated with idiopathic VF and has been termed as ERS. This condition is mainly observed in young men, athletes, and blacks. Also, it has become evident that electrocardiographic territory, degree of J-point elevation, and ST-segment morphology are associated with different levels of risk for subsequent ventricular arrhythmia. However, it is unclear whether J waves are more strongly associated with a depolarization abnormality rather than a repolarization abnormality. Several clinical entities can cause ST-segment elevation. Therefore, clinical and ECG data are essential for differential diagnosis. At present, the data set is insufficient to allow risk stratification in asymptomatic individuals. ERS, idiopathic VF, and Brugada syndrome (known as J-wave syndromes) are three clinical conditions that share many common ECG features; however, their clinical consequences are remarkably different. This review summarizes the current electrocardiographic data concerning ERS with clinical implications.
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Affiliation(s)
- Ciprian Rezus
- III Medical Clinic of "Sf. Spiridon" University Hospital; Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania
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