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Leung KSK, Radford D, Huang H, Lakhani I, Li CKH, Hothi SS, Wai AKC, Liu T, Tse G, Lee S. Risk stratification of sudden cardiac death in asymptomatic female Brugada syndrome patients: A literature review. Ann Noninvasive Electrocardiol 2023; 28:e13030. [PMID: 36628595 PMCID: PMC10023885 DOI: 10.1111/anec.13030] [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: 11/18/2022] [Accepted: 11/30/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Risk stratification in Brugada syndrome remains a difficult problem. Given the male predominance of this disease and their elevated risks of arrhythmic events, affected females have received less attention. It is widely known that symptomatic patients are at increased risk of sudden cardiac death (SCD) than asymptomatic patients, while this might be true in the male population; recent studies have shown that this association might not be significant in females. Over the past few decades, numerous markers involving clinical symptoms, electrocardiographic (ECG) indices, and genetic tests have been explored, with several risk-scoring models developed so far. The objective of this study is to review the current evidence of clinical and ECG markers as well as risk scores on asymptomatic females with Brugada syndrome. FINDINGS Gender differences in ECG markers, the yield of genetic findings, and the applicability of risk scores are highlighted. CONCLUSIONS Various clinical, electrocardiographic, and genetic risk factors are available for assessing SCD risk amongst asymptomatic female BrS patients. However, due to the significant gender discrepancy in BrS, the SCD risk amongst females is often underestimated, and there is a lack of research on female-specific risk factors and multiparametric risk scores. Therefore, multinational studies pooling female BrS patients are needed for the development of a gender-specific risk stratification approach amongst asymptomatic BrS patients.
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Affiliation(s)
- Keith Sai Kit Leung
- Cardiac Electrophysiology UnitCardiovascular Analytics GroupHong KongChina
- Faculty of Health and Life SciencesAston University Medical SchoolBirminghamUK
| | - Danny Radford
- Kent and Medway Medical SchoolUniversity of Kent and Canterbury Christ Church UniversityCanterburyUK
| | - Helen Huang
- University of Medicine and Health Science, Royal College of Surgeons in IrelandDublinIreland
| | - Ishan Lakhani
- Cardiac Electrophysiology UnitCardiovascular Analytics GroupHong KongChina
| | | | - Sandeep Singh Hothi
- Heart and Lung CentreNew Cross Hospital, Royal Wolverhampton NHS TrustWolverhamptonUK
| | | | - Tong Liu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Gary Tse
- Cardiac Electrophysiology UnitCardiovascular Analytics GroupHong KongChina
- Kent and Medway Medical SchoolUniversity of Kent and Canterbury Christ Church UniversityCanterburyUK
- Emergency Medicine UnitUniversity of Hong KongHong KongChina
| | - Sharen Lee
- Cardiac Electrophysiology UnitCardiovascular Analytics GroupHong KongChina
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Popa IP, Șerban DN, Mărănducă MA, Șerban IL, Tamba BI, Tudorancea I. Brugada Syndrome: From Molecular Mechanisms and Genetics to Risk Stratification. Int J Mol Sci 2023; 24:ijms24043328. [PMID: 36834739 PMCID: PMC9967917 DOI: 10.3390/ijms24043328] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/13/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Brugada syndrome (BrS) is a rare hereditary arrhythmia disorder, with a distinctive ECG pattern, correlated with an increased risk of ventricular arrhythmias and sudden cardiac death (SCD) in young adults. BrS is a complex entity in terms of mechanisms, genetics, diagnosis, arrhythmia risk stratification, and management. The main electrophysiological mechanism of BrS requires further research, with prevailing theories centered on aberrant repolarization, depolarization, and current-load match. Computational modelling, pre-clinical, and clinical research show that BrS molecular anomalies result in excitation wavelength (k) modifications, which eventually increase the risk of arrhythmia. Although a mutation in the SCN5A (Sodium Voltage-Gated Channel Alpha Subunit 5) gene was first reported almost two decades ago, BrS is still currently regarded as a Mendelian condition inherited in an autosomal dominant manner with incomplete penetrance, despite the recent developments in the field of genetics and the latest hypothesis of additional inheritance pathways proposing a more complex mode of inheritance. In spite of the extensive use of the next-generation sequencing (NGS) technique with high coverage, genetics remains unexplained in a number of clinically confirmed cases. Except for the SCN5A which encodes the cardiac sodium channel NaV1.5, susceptibility genes remain mostly unidentified. The predominance of cardiac transcription factor loci suggests that transcriptional regulation is essential to the Brugada syndrome's pathogenesis. It appears that BrS is a multifactorial disease, which is influenced by several loci, each of which is affected by the environment. The primary challenge in individuals with a BrS type 1 ECG is to identify those who are at risk for sudden death, researchers propose the use of a multiparametric clinical and instrumental strategy for risk stratification. The aim of this review is to summarize the latest findings addressing the genetic architecture of BrS and to provide novel perspectives into its molecular underpinnings and novel models of risk stratification.
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Affiliation(s)
- Irene Paula Popa
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Dragomir N. Șerban
- Department of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Minela Aida Mărănducă
- Department of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Ionela Lăcrămioara Șerban
- Department of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Bogdan Ionel Tamba
- Department of Pharmacology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
- Correspondence:
| | - Ionuț Tudorancea
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
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Aziz HM, Zarzecki MP, Garcia-Zamora S, Kim MS, Bijak P, Tse G, Won HH, Matusik PT. Pathogenesis and Management of Brugada Syndrome: Recent Advances and Protocol for Umbrella Reviews of Meta-Analyses in Major Arrhythmic Events Risk Stratification. J Clin Med 2022; 11:jcm11071912. [PMID: 35407520 PMCID: PMC8999897 DOI: 10.3390/jcm11071912] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/14/2022] [Accepted: 03/25/2022] [Indexed: 12/13/2022] Open
Abstract
Brugada syndrome (BrS) is a primary electrical disease associated with life-threatening arrhythmias. It is estimated to cause at least 20% of sudden cardiac deaths (SCDs) in patients with normal cardiac anatomy. In this review paper, we discuss recent advances in complex BrS pathogenesis, diagnostics, and current standard approaches to major arrhythmic events (MAEs) risk stratification. Additionally, we describe a protocol for umbrella reviews to systematically investigate clinical, electrocardiographic, electrophysiological study, programmed ventricular stimulation, and genetic factors associated with BrS, and the risk of MAEs. Our evaluation will include MAEs such as sustained ventricular tachycardia, ventricular fibrillation, appropriate implantable cardioverter–defibrillator therapy, sudden cardiac arrest, and SCDs from previous meta-analytical studies. The protocol was written following the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines. We plan to extensively search PubMed, Embase, and Scopus databases for meta-analyses concerning risk-stratification in BrS. Data will be synthesized integratively with transparency and accuracy. Heterogeneity patterns across studies will be reported. The Joanna Briggs Institute (JBI) methodology, A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2), and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) are planned to be applied for design and execution of our evidence-based research. To the best of our knowledge, these will be the first umbrella reviews to critically evaluate the current state of knowledge in BrS risk stratification for life-threatening ventricular arrhythmias, and will potentially contribute towards evidence-based guidance to enhance clinical decisions.
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Affiliation(s)
- Hasina Masha Aziz
- Faculty of Medicine, Jagiellonian University Medical College, 31-530 Kraków, Poland;
| | - Michał P. Zarzecki
- Department of Anatomy, Jagiellonian University Medical College, 31-034 Kraków, Poland;
| | | | - Min Seo Kim
- Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Samsung Medical Center, Seoul 06351, Korea;
| | - Piotr Bijak
- John Paul II Hospital, 31-202 Kraków, Poland;
| | - Gary Tse
- Cardiac Electrophysiology Unit, Cardiovascular Analytics Group, Hong Kong, China;
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300070, China
- Kent and Medway Medical School, University of Kent and Canterbury Christ Church University, Canterbury CT2 7FS, UK
| | - Hong-Hee Won
- Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Samsung Genome Institute, Samsung Medical Center, Seoul 06351, Korea;
| | - Paweł T. Matusik
- Department of Electrocardiology, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, 31-202 Kraków, Poland
- Department of Electrocardiology, The John Paul II Hospital, 31-202 Kraków, Poland
- Correspondence:
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Lee S, Wong WT, Wong ICK, Mak C, Mok NS, Liu T, Tse G. Ventricular Tachyarrhythmia Risk in Paediatric/Young vs. Adult Brugada Syndrome Patients: A Territory-Wide Study. Front Cardiovasc Med 2021; 8:671666. [PMID: 34179137 PMCID: PMC8225934 DOI: 10.3389/fcvm.2021.671666] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/18/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction: Brugada syndrome (BrS) is a cardiac ion channelopathy with a higher prevalence in Asia compared to the Western populations. The present study compared the differences in clinical and electrocardiographic (ECG) presentation between paediatric/young (≤25 years old) and adult (>25 years) BrS patients. Method: This was a territory-wide retrospective cohort study of consecutive BrS patients presenting to public hospitals in Hong Kong. The primary outcome was spontaneous ventricular tachycardia/ventricular fibrillation (VT/VF). Results: The cohort consists of 550 consecutive patients (median age of initial presentation = 51 ± 23 years; female = 7.3%; follow-up period = 83 ± 80 months), divided into adult (n = 505, mean age of initial presentation = 52 ± 19 years; female = 6.7%; mean follow-up period = 83 ± 80 months) and paediatric/young subgroups (n = 45, mean age of initial presentation = 21 ± 5 years, female = 13.3%, mean follow-up period = 73 ± 83 months). The mean annual VT/VF incidence rate were 17 and 25 cases per 1,000 patient-year, respectively. Multivariate analysis showed that initial presentation of type 1 pattern (HR = 1.80, 95% CI = [1.02, 3.15], p = 0.041), initial asymptomatic presentation (HR = 0.26, 95% CI = [0.07, 0.94], p = 0.040) and increased P-wave axis (HR = 0.98, 95% CI = [0.96, 1.00], p = 0.036) were significant predictors of VT/VF for the adult subgroup. Only initial presentation of VT/VF was predictive (HR = 29.30, 95% CI = [1.75, 492.00], p = 0.019) in the paediatric/young subgroup. Conclusion: Clinical and ECG presentation of BrS vary between the paediatric/young and adult population in BrS. Risk stratification and management strategies for younger patients should take into consideration and adopt an individualised approach.
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Affiliation(s)
- Sharen Lee
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong, China
| | - Wing Tak Wong
- State Key Laboratory of Agrobiotechnology (CUHK), School of Life Sciences, Chinese University of Hong Kong, Hong Kong, China
| | - Ian Chi Kei Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.,School of Pharmacy, University College London, London, United Kingdom
| | - Chloe Mak
- Department of Pathology, Hong Kong Children's Hospital, Hong Kong, China
| | - Ngai Shing Mok
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, China
| | - Tong Liu
- 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
| | - 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.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom.,Kent and Medway Medical School, Canterbury, United Kingdom
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5
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Lee S, Zhou J, Li KHC, Leung KSK, Lakhani I, Liu T, Wong ICK, Mok NS, Mak C, Jeevaratnam K, Zhang Q, Tse G. Territory-wide cohort study of Brugada syndrome in Hong Kong: predictors of long-term outcomes using random survival forests and non-negative matrix factorisation. Open Heart 2021; 8:e001505. [PMID: 33547222 PMCID: PMC7871343 DOI: 10.1136/openhrt-2020-001505] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Brugada syndrome (BrS) is an ion channelopathy that predisposes affected patients to spontaneous ventricular tachycardia/fibrillation (VT/VF) and sudden cardiac death. The aim of this study is to examine the predictive factors of spontaneous VT/VF. METHODS This was a territory-wide retrospective cohort study of patients diagnosed with BrS between 1997 and 2019. The primary outcome was spontaneous VT/VF. Cox regression was used to identify significant risk predictors. Non-linear interactions between variables (latent patterns) were extracted using non-negative matrix factorisation (NMF) and used as inputs into the random survival forest (RSF) model. RESULTS This study included 516 consecutive BrS patients (mean age of initial presentation=50±16 years, male=92%) with a median follow-up of 86 (IQR: 45-118) months. The cohort was divided into subgroups based on initial disease manifestation: asymptomatic (n=314), syncope (n=159) or VT/VF (n=41). Annualised event rates per person-year were 1.70%, 0.05% and 0.01% for the VT/VF, syncope and asymptomatic subgroups, respectively. Multivariate Cox regression analysis revealed initial presentation of VT/VF (HR=24.0, 95% CI=1.21 to 479, p=0.037) and SD of P-wave duration (HR=1.07, 95% CI=1.00 to 1.13, p=0.044) were significant predictors. The NMF-RSF showed the best predictive performance compared with RSF and Cox regression models (precision: 0.87 vs 0.83 vs. 0.76, recall: 0.89 vs. 0.85 vs 0.73, F1-score: 0.88 vs 0.84 vs 0.74). CONCLUSIONS Clinical history, electrocardiographic markers and investigation results provide important information for risk stratification. Machine learning techniques using NMF and RSF significantly improves overall risk stratification performance.
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Affiliation(s)
- Sharen Lee
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong, China
| | - Jiandong Zhou
- School of Data Science, City University of Hong Kong, Kowloon, Hong Kong
| | - Ka Hou Christien Li
- Faculty of Medicine, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | | | - Ishan Lakhani
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Ian Chi Kei Wong
- Research department of Practice and Policy, University College London School of Pharmacy, London, UK
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
| | - Ngai Shing Mok
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong, Hong Kong
| | - Chloe Mak
- Department of Pathology, Hong Kong Children's Hospital, Hong Kong, Hong Kong
| | - Kamalan Jeevaratnam
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Kowloon, Hong Kong
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK
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Tse G, Lee S, Li A, Chang D, Li G, Zhou J, Liu T, Zhang Q. Automated Electrocardiogram Analysis Identifies Novel Predictors of Ventricular Arrhythmias in Brugada Syndrome. Front Cardiovasc Med 2021; 7:618254. [PMID: 33521066 PMCID: PMC7840575 DOI: 10.3389/fcvm.2020.618254] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/17/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Patients suffering from Brugada syndrome (BrS) are at an increased risk of life-threatening ventricular arrhythmias. Whilst electrocardiographic (ECG) variables have been used for risk stratification with varying degrees of success, automated measurements have not been tested for their ability to predict adverse outcomes in BrS. Methods: BrS patients presenting in a single tertiary center between 2000 and 2018 were analyzed retrospectively. ECG variables on vector magnitude, axis, amplitude and duration from all 12 leads were determined. The primary endpoint was spontaneous ventricular tachycardia/ventricular fibrillation (VT/VF) on follow-up. Results: This study included 83 patients [93% male, median presenting age: 56 (41–66) years old, 45% type 1 pattern] with 12 developing the primary endpoint (median follow-up: 75 (Q1–Q3: 26–114 months). Cox regression showed that QRS frontal axis > 70.0 degrees, QRS horizontal axis > 57.5 degrees, R-wave amplitude (lead I) <0.67 mV, R-wave duration (lead III) > 50.0 ms, S-wave amplitude (lead I) < −0.144 mV, S-wave duration (lead aVL) > 35.5 ms, QRS duration (lead V3) > 96.5 ms, QRS area in lead I < 0.75 Ashman units, ST slope (lead I) > 31.5 deg, T-wave area (lead V1) < −3.05 Ashman units and PR interval (lead V2) > 157 ms were significant predictors. A weighted score based on dichotomized values provided good predictive performance (hazard ratio: 1.59, 95% confidence interval: 1.27–2.00, P-value<0.0001, area under the curve: 0.84). Conclusions: Automated ECG analysis revealed novel risk markers in BrS. These markers should be validated in larger prospective studies.
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Affiliation(s)
- 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
| | - Sharen Lee
- Laboratory of Cardiovascular Physiology, Faculty of Medicine, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Andrew Li
- Faculty of Science, University of Calgary, Calgary, AB, Canada
| | - Dong Chang
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
| | - Guangping Li
- 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
| | - Jiandong Zhou
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Tong Liu
- 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
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Hong Kong, China
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Lee S, Zhou J, Liu T, Letsas KP, Hothi SS, Vassiliou VS, Li G, Baranchuk A, Sy RW, Chang D, Zhang Q, Tse G. Temporal Variability in Electrocardiographic Indices in Subjects With Brugada Patterns. Front Physiol 2020; 11:953. [PMID: 33013434 PMCID: PMC7494959 DOI: 10.3389/fphys.2020.00953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/15/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction Patients with Brugada electrocardiographic (ECG) patterns have differing levels of arrhythmic risk. We hypothesized that temporal variations in certain ECG markers may provide additional value for risk stratification. The present study evaluated the relationship between temporal variability of ECG markers and arrhythmic outcomes in patients with a Brugada pattern ECG. Comparisons were made between low-risk asymptomatic subjects versus high-risk symptomatic patients with a history of syncope, ventricular tachycardia (VT) or ventricular fibrillation (VF). Methods A total of 81 patients presenting with Brugada patterns were recruited. Serial ECGs and electronic health records from January 2004 to April 2019 were analyzed. Temporal variability of QRS interval, J point-Tpeak interval (JTp), Tpeak-Tend interval (Tp-e), and ST elevation (STe) in precordial leads V1-3, in addition to RR-interval from lead II, was assessed using standard deviation and difference between maximum and minimum values over the serial ECGs. Results Patients presenting with type 1 Brugada ECG pattern initially had significantly higher variability in JTp from lead V2 (SD: 33.5 ± 13.8 vs. 25.2 ± 11.5 ms, P = 0.009; max-min: 98.6 ± 46.2 vs. 78.3 ± 47.6 ms, P = 0.047) and ST elevation in lead V1 (0.117 ± 0.122 vs. 0.053 ± 0.030 mV; P = 0.004). Significantly higher variability in Tp-e interval measured from lead V3 was observed in the VT/VF group compared to the syncope and asymptomatic groups (SD: 20.5 ± 8.5 vs. 16.6 ± 7.3 and 14.7 ± 9.8 ms; P = 0.044; max-min: 70.2 ± 28.9 vs. 56.3 ± 29.0 and 43.5 ± 28.5 ms; P = 0.011). Conclusion Temporal variability in ECG indices may provide additional value for risk stratification in patients with Brugada pattern.
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Affiliation(s)
- Sharen Lee
- Laboratory of Cardiovascular Physiology, Li Ka Shing Institute of Health Sciences, Hong Kong, China
| | - Jiandong Zhou
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Tong Liu
- 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
| | - Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Sandeep S Hothi
- Heart and Lung Centre, New Cross Hospital, Wolverhampton, United Kingdom
| | - Vassilios S Vassiliou
- Norwich Medical School, University of East Anglia, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Guoliang Li
- Arrhythmia Unit, Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Raymond W Sy
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Dong Chang
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Hong Kong, 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.,Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
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Rattanawong P, Kewcharoen J, Techorueangwiwat C, Kanitsoraphan C, Mekritthikrai R, Prasitlumkum N, Puttapiban P, Mekraksakit P, Vutthikraivit W, Sorajja D. Wide QRS complex and the risk of major arrhythmic events in Brugada syndrome patients: A systematic review and meta-analysis. J Arrhythm 2020; 36:143-152. [PMID: 32071633 PMCID: PMC7011812 DOI: 10.1002/joa3.12290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/18/2019] [Accepted: 12/01/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Brugada syndrome (BrS) is an inherited arrhythmic disease associated with an increased risk of major arrhythmic events (MAE). Previous studies reported that a wide QRS complex may be useful as a predictor of MAE in BrS patients. We aimed to assess the correlation of wide QRS complex with MAE by a systematic review and meta-analysis. METHODS We comprehensively searched the databases of MEDLINE and EMBASE from inception to June 2019. Included studies were cohort and case control studies that reported QRS duration and the relationship between wide QRS complex (>120 milliseconds) and MAE (sudden cardiac death, sudden cardiac arrest, ventricular fibrillation, sustained ventricular tachycardia, or appropriate shock). Data from each study were combined using the random-effects model. RESULTS Twenty-two studies from 2007 to 2018 were included in this meta-analysis involving 4,814 BrS patients. The mean age was 46.1 ± 12.8 years. The patients were predominately men (77.6%). Wide QRS duration was an independent predictor of MAE (pooled risk ratio 1.55, 95% confidence interval: 1.04-2.30, P = .30, I 2 = 38.4%). QRS duration was wider in BrS who had history of MAE (weight mean difference = 8.12 milliseconds, 95% confidence interval: 5.75-10.51 milliseconds). CONCLUSIONS Our study demonstrated that QRS duration is wider in BrS who had history of MAE, and a wide QRS complex is associated with 1.55 times higher risk of MAE in BrS populations. Wide QRS complex can be considered for risk stratification in prediction of MAE in patients with BrS, especially when considering implantable cardioverter-defibrillator placement in asymptomatic patients.
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Affiliation(s)
- Pattara Rattanawong
- Department of Cardiovascular MedicineMayo ClinicPhoenixAZUSA
- Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Jakrin Kewcharoen
- University of Hawaii Internal Medicine Residency ProgramHonoluluHIUSA
| | | | | | | | | | | | - Poemlarp Mekraksakit
- Department of Internal MedicineTexas Tech University Health Sciences CenterLubbockTXUSA
| | - Wasawat Vutthikraivit
- Department of Internal MedicineTexas Tech University Health Sciences CenterLubbockTXUSA
| | - Dan Sorajja
- Department of Cardiovascular MedicineMayo ClinicPhoenixAZUSA
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9
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Li KHC, Lee S, Yin C, Liu T, Ngarmukos T, Conte G, Yan GX, Sy RW, Letsas KP, Tse G. Brugada syndrome: A comprehensive review of pathophysiological mechanisms and risk stratification strategies. IJC HEART & VASCULATURE 2020; 26:100468. [PMID: 31993492 PMCID: PMC6974766 DOI: 10.1016/j.ijcha.2020.100468] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 01/01/2020] [Accepted: 01/02/2020] [Indexed: 12/17/2022]
Abstract
Brugada syndrome (BrS) is an inherited ion channel channelopathy predisposing to ventricular arrhythmias and sudden cardiac death. Originally believed to be predominantly associated with mutations in SCN5A encoding for the cardiac sodium channel, mutations of 18 genes other than SCN5A have been implicated in the pathogenesis of BrS to date. Diagnosis is based on the presence of a spontaneous or drug-induced coved-type ST segment elevation. The predominant electrophysiological mechanism underlying BrS remains disputed, commonly revolving around the three main hypotheses based on abnormal repolarization, depolarization or current-load match. Evidence from computational modelling, pre-clinical and clinical studies illustrates that molecular abnormalities found in BrS lead to alterations in excitation wavelength (λ), which ultimately elevates arrhythmic risk. A major challenge for clinicians in managing this condition is the difficulty in predicting the subset of patients who will suffer from life-threatening ventricular arrhythmic events. Several repolarization risk markers have been used thus far, but these neglect the contributions of conduction abnormalities in the form of slowing and dispersion. Indices incorporating both repolarization and conduction based on the concept of λ have recently been proposed. These may have better predictive values than the existing markers. Current treatment options include pharmacological therapy to reduce the occurrence of arrhythmic events or to abort these episodes, and interventions such as implantable cardioverter-defibrillator insertion or radiofrequency ablation of abnormal arrhythmic substrate.
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Affiliation(s)
- Ka Hou Christien Li
- Faculty of Medicine, Newcastle University, Newcastle, United Kingdom.,Laboratory of Cardiovascular Physiology, Li Ka Shing Institute of Health Sciences, Hong Kong, SAR, PR China
| | - Sharen Lee
- Laboratory of Cardiovascular Physiology, Li Ka Shing Institute of Health Sciences, Hong Kong, SAR, PR China
| | - Chengye Yin
- School of Biological and Chemical Sciences, Queen Mary University of London, London, United Kingdom
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, PR China
| | - Tachapong Ngarmukos
- Department of Medicine Faculty of Medicine Ramathibodi Hospital Mahidol University, Bangkok, Thailand
| | - Giulio Conte
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Gan-Xin Yan
- Lankenau Institute for Medical Research and Lankenau Medical Center, Wynnewood, PA, USA
| | - Raymond W Sy
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - 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 300211, PR China.,Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
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Tse G, Gong M, Li CKH, Leung KSK, Georgopoulos S, Bazoukis G, Letsas KP, Sawant AC, Mugnai G, Wong MC, Yan GX, Brugada P, Chierchia G, de Asmundis C, Baranchuk A, Liu T. T peak-T end, T peak-T end/QT ratio and T peak-T end dispersion for risk stratification in Brugada Syndrome: A systematic review and meta-analysis. J Arrhythm 2018; 34:587-597. [PMID: 30555602 PMCID: PMC6288557 DOI: 10.1002/joa3.12118] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 07/30/2018] [Accepted: 08/14/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Brugada syndrome is an ion channelopathy that predisposes affected subjects to ventricular tachycardia/fibrillation (VT/VF), potentially leading to sudden cardiac death (SCD). Tpeak-Tend intervals, (Tpeak-Tend)/QT ratio and Tpeak-Tend dispersion have been proposed for risk stratification, but their predictive values in Brugada syndrome have been challenged recently. METHODS A systematic review and meta-analysis was conducted to examine their values in predicting arrhythmic and mortality outcomes in Brugada Syndrome. PubMed and Embase databases were searched until 1 May 2018, identifying 29 and 57 studies. RESULTS Nine studies involving 1740 subjects (mean age 45 years old, 80% male, mean follow-up duration was 68 ± 27 months) were included. The mean Tpeak-Tend interval was 98.9 ms (95% CI: 90.5-107.2 ms) for patients with adverse events (ventricular arrhythmias or SCD) compared to 87.7 ms (95% CI: 80.5-94.9 ms) for those without such events, with a mean difference of 11.9 ms (95% CI: 3.6-20.2 ms, P = 0.005; I 2 = 86%). Higher (Tpeak-Tend)/QT ratios (mean difference = 0.019, 95% CI: 0.003-0.036, P = 0.024; I 2 = 74%) and Tpeak-Tend dispersion (mean difference = 7.8 ms, 95% CI: 2.1-13.4 ms, P = 0.007; I 2 = 80%) were observed for the event-positive group. CONCLUSION Tpeak-Tend interval, (Tpeak-Tend)/QT ratio and Tpeak-Tend dispersion were higher in high-risk than low-risk Brugada subjects, and thus offer incremental value for risk stratification.
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Affiliation(s)
- Gary Tse
- Department of Medicine and Therapeutics, Faculty of MedicineChinese University of Hong KongHong KongChina
- Li Ka Shing Institute of Health Sciences, Faculty of MedicineChinese University of Hong KongHong KongChina
- Shenzhen Research InstituteThe Chinese University of Hong KongShenzhenChina
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Christien Ka Hou Li
- Department of Medicine and Therapeutics, Faculty of MedicineChinese University of Hong KongHong KongChina
- Li Ka Shing Institute of Health Sciences, Faculty of MedicineChinese University of Hong KongHong KongChina
- Shenzhen Research InstituteThe Chinese University of Hong KongShenzhenChina
- Faculty of MedicineNewcastle UniversityNewcastleUK
| | - Keith Sai Kit Leung
- Department of Medicine and Therapeutics, Faculty of MedicineChinese University of Hong KongHong KongChina
- Li Ka Shing Institute of Health Sciences, Faculty of MedicineChinese University of Hong KongHong KongChina
- Shenzhen Research InstituteThe Chinese University of Hong KongShenzhenChina
- Aston Medical SchoolAston UniversityBirminghamUK
| | - Stamatis Georgopoulos
- Second Department of Cardiology, Laboratory of Cardiac ElectrophysiologyEvangelismos General Hospital of AthensAthensGreece
| | - George Bazoukis
- Second Department of Cardiology, Laboratory of Cardiac ElectrophysiologyEvangelismos General Hospital of AthensAthensGreece
| | - Konstantinos P. Letsas
- Second Department of Cardiology, Laboratory of Cardiac ElectrophysiologyEvangelismos General Hospital of AthensAthensGreece
| | - Abhishek C. Sawant
- Division of Cardiology, Department of Internal MedicineState University of New York at BuffaloBuffaloNew York
| | - Giacomo Mugnai
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and PacingUniversitair Ziekenhuis Brussel‐Vrije Universiteit BrusselBrusselsBelgium
| | - Martin C.S. Wong
- JC School of Public Health and Primary CareThe Chinese University of Hong KongHong KongChina
| | - Gan Xin Yan
- Lankenau Institute for Medical Research and Lankenau Medical CenterWynnewoodPennsylvania
- Beijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Pedro Brugada
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and PacingUniversitair Ziekenhuis Brussel‐Vrije Universiteit BrusselBrusselsBelgium
| | - Gian‐Battista Chierchia
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and PacingUniversitair Ziekenhuis Brussel‐Vrije Universiteit BrusselBrusselsBelgium
| | - Carlo de Asmundis
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and PacingUniversitair Ziekenhuis Brussel‐Vrije Universiteit BrusselBrusselsBelgium
| | - Adrian Baranchuk
- Division of CardiologyKingston General Hospital, Queen's UniversityKingstonONCanada
| | - Tong Liu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular Disease, Department of CardiologyTianjin Institute of Cardiology, Second Hospital of Tianjin Medical UniversityTianjinChina
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Tse G, Li KHC, Li G, Liu T, Bazoukis G, Wong WT, Chan MTV, Wong MCS, Xia Y, Letsas KP, Chan GCP, Chan YS, Wu WKK. Higher Dispersion Measures of Conduction and Repolarization in Type 1 Compared to Non-type 1 Brugada Syndrome Patients: An Electrocardiographic Study From a Single Center. Front Cardiovasc Med 2018; 5:132. [PMID: 30338262 PMCID: PMC6180153 DOI: 10.3389/fcvm.2018.00132] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 09/04/2018] [Indexed: 12/26/2022] Open
Abstract
Background: Brugada syndrome (BrS) is a cardiac ion channelopathy that predisposes affected individuals to sudden cardiac death (SCD). Type 1 BrS is thought to take a more malignant clinical course than non-type 1 BrS. We hypothesized that the degrees of abnormal repolarization and conduction are greater in type 1 subjects and these differences can be detected by electrocardiography (ECG). Methods: Electrocardiographic data from spontaneous type 1 and non-type 1 BrS patients were analyzed. ECG parameters were measured from leads V1 to V3. Values were expressed as median [lower quartile-upper quartile] and compared using Kruskal-Wallis ANOVA. Results: Compared to non-type 1 BrS patients (n = 29), patients with spontaneous type 1 patterns (n = 22) showed similar (P > 0.05) heart rate (73 [64-77] vs. 68 [62-80] bpm), QRS duration (136 [124-161] vs. 127 [117-144] ms), uncorrected QT (418 [393-443] vs. 402 [386-424] ms) and corrected QT intervals (457 [414-474] vs. 430 [417-457] ms), JTpeak intervals (174 [144-183] vs. 174 [150-188] ms), Tpeak- Tend intervals (101 [93-120] vs. 99 [90-105] ms), Tpeak- Tend/QT ratios (0.25 [0.23-0.27] vs. 0.24 [0.22-0.27]), Tpeak- Tend/QRS (0.77 [0.62-0.87] vs. 0.77 [0.69-0.86]), Tpeak- Tend/(QRS × QT) (0.00074 [0.00034-0.00096] vs. 0.00073 [0.00048-0.00012] ms-1), index of Cardiac Electrophysiological Balance (iCEB, QT/QRS, marker of wavelength: 3.14 [2.56-3.35] vs. 3.21 [2.85-3.46]) and corrected iCEB (QTc/QRS: 3.25 [2.91-3.73] vs. 3.49 [2.99-3.78]). Higher QRS dispersion was seen in type 1 subjects (QRSd: 34 [24-66] vs. 24 [12-34] ms) but QT dispersion (QTd: 48 [39-71] vs. 43 [22-94] ms), QTc dispersion (QTcd: 52 [41-79] vs. 46 [23-104] ms), JTpeak dispersion (44 [23-62] vs. 45 [30-62] ms), Tpeak- Tend dispersion (28 [15-34] vs. 29 [22-53] ms) or Tpeak- Tend/QT dispersion (0.06 [0.03-0.08] vs. 0.08 [0.04-0.12]) did not differ between the two groups. Type 1 subjects showed higher (QRSd × Tpeak- Tend)/QRS (25 [19-44] vs. 19 [9-30] ms) but similar iCEB dispersion (0.83 [0.49-1.14] vs. 0.61 [0.34-0.92]) and iCEBc dispersion (0.93 [0.51-1.15] vs. 0.65 [0.39-0.96]). Conclusion: Higher levels of dispersion in conduction and repolarization are found in type 1 than non-type 1 BrS patients, potentially explaining the higher incidence of ventricular arrhythmias in the former group.
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Affiliation(s)
- Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Ka Hou Christien Li
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
- Faculty of Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Guangping Li
- 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
| | - Tong Liu
- 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
| | - George Bazoukis
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Wing Tak Wong
- School of Life Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Matthew T. V. Chan
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Martin C. S. Wong
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Yunlong Xia
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Konstantinos P. Letsas
- Laboratory of Cardiac Electrophysiology, Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Gary Chin Pang Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Yat Sun Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - William K. K. Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
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