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Sarquella-Brugada G, Martínez-Barrios E, Cesar S, Toro R, Cruzalegui J, Greco A, Díez-Escuté N, Cerralbo P, Chipa F, Arbelo E, Diez-López C, Grazioli G, Balderrábano N, Campuzano O. A narrative review of inherited arrhythmogenic syndromes in young population: role of genetic diagnosis in exercise recommendations. BMJ Open Sport Exerc Med 2024; 10:e001852. [PMID: 38975025 PMCID: PMC11227825 DOI: 10.1136/bmjsem-2023-001852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 07/09/2024] Open
Abstract
Sudden cardiac death is a rare but socially devastating event, especially if occurs in young people. Usually, this unexpected lethal event occurs during or just after exercise. One of the leading causes of sudden cardiac death is inherited arrhythmogenic syndromes, a group of genetic entities characterised by incomplete penetrance and variable expressivity. Exercise can be the trigger for malignant arrhythmias and even syncope in population with a genetic predisposition, being sudden cardiac death as the first symptom. Due to genetic origin, family members must be clinically assessed and genetically analysed after diagnosis or suspected diagnosis of a cardiac channelopathy. Early identification and adoption of personalised preventive measures is crucial to reduce risk of arrhythmias and avoid new lethal episodes. Despite exercise being recommended by the global population due to its beneficial effects on health, particular recommendations for these patients should be adopted considering the sport practised, level of demand, age, gender, arrhythmogenic syndrome diagnosed but also genetic diagnosis. Our review focuses on the role of genetic background in sudden cardiac death during exercise in child and young population.
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Affiliation(s)
- Georgia Sarquella-Brugada
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Malalties Cardiovasculars en el Desenvolupament, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Amsterdam, The Netherlands
- Medical Science Department, School of Medicine, Universitat de Girona, Girona, Spain
| | - Estefanía Martínez-Barrios
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Malalties Cardiovasculars en el Desenvolupament, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Amsterdam, The Netherlands
| | - Sergi Cesar
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Malalties Cardiovasculars en el Desenvolupament, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Amsterdam, The Netherlands
| | - Rocío Toro
- Medicine Department, School of Medicine, University of Cádiz, Cádiz, Spain
| | - José Cruzalegui
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Malalties Cardiovasculars en el Desenvolupament, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Amsterdam, The Netherlands
| | - Andrea Greco
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Malalties Cardiovasculars en el Desenvolupament, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Amsterdam, The Netherlands
| | - Nuria Díez-Escuté
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Malalties Cardiovasculars en el Desenvolupament, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Amsterdam, The Netherlands
| | - Patricia Cerralbo
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Malalties Cardiovasculars en el Desenvolupament, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Amsterdam, The Netherlands
| | - Fredy Chipa
- Pediatric Arrhythmias, Inherited Cardiac Diseases and Sudden Death Unit, Hospital Sant Joan de Déu, Barcelona, Spain
- Arrítmies Pediàtriques, Cardiologia Genètica i Mort Sobtada, Malalties Cardiovasculars en el Desenvolupament, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Amsterdam, The Netherlands
| | - Elena Arbelo
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart (ERN GUARD-Heart), Amsterdam, The Netherlands
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigació August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Carles Diez-López
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL) Hospitalet de Llobregat, Barcelona, Spain
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Bellvitge University Hospital Hospitalet de Llobregat, Barcelona, Spain
| | | | - Norma Balderrábano
- Cardiology Department, Children Hospital of Mexico Federico Gómez, México D.F, Mexico
| | - Oscar Campuzano
- Medical Science Department, School of Medicine, Universitat de Girona, Girona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Cardiovascular Genetics Center, Institut d'Investigació Biomèdiques de Girona (IDIBGI), Salt-Girona, Spain
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2
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Ciriello GD, Romeo E, Colonna D, Correra A, Russo MG, Sarubbi B. Exercise-induced type 1 Brugada pattern in a child. Pacing Clin Electrophysiol 2024. [PMID: 38852070 DOI: 10.1111/pace.15024] [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: 05/20/2024] [Accepted: 05/27/2024] [Indexed: 06/10/2024]
Abstract
The exercise stress testing may unmask the type 1 Brugada pattern on the surface electrocardiogram in a portion of patients with Brugada syndrome. The occurrence of the type 1 Brugada pattern during an exercise test in pediatric patients is not common. Consequently, the diagnostic yield of the exercise test in this population is still to be explored. We present a case of exercise-induced type 1 Brugada pattern in a 12-year-old child with episodes of palpitations and discuss the available evidence on the role of the exercise stress test in the diagnosis and risk stratification of patients with Brugada syndrome.
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Affiliation(s)
- Giovanni Domenico Ciriello
- Adult Congenital Heart Disease and Congenital and Familial Arrhythmias Unit, Monaldi Hospital, Naples, Italy
| | - Emanuele Romeo
- Adult Congenital Heart Disease and Congenital and Familial Arrhythmias Unit, Monaldi Hospital, Naples, Italy
| | - Diego Colonna
- Adult Congenital Heart Disease and Congenital and Familial Arrhythmias Unit, Monaldi Hospital, Naples, Italy
| | - Anna Correra
- Adult Congenital Heart Disease and Congenital and Familial Arrhythmias Unit, Monaldi Hospital, Naples, Italy
| | - Maria Giovanna Russo
- Pediatric Cardiology Unit, "L. Vanvitelli" University, Monaldi Hospital, Naples, Italy
| | - Berardo Sarubbi
- Adult Congenital Heart Disease and Congenital and Familial Arrhythmias Unit, Monaldi Hospital, Naples, Italy
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Pichara NL, Sacilotto L, Scanavacca MI, Cardoso AF, Soares BMAF, Falcochio PPPNF, Falcão AMG, Olivetti N, da Costa Darrieux FC, Chalela WA. Evaluation of a new treadmill exercise protocol to unmask type 1 Brugada electrocardiographic pattern: can we improve diagnostic yield? Europace 2023; 25:euad157. [PMID: 37410808 PMCID: PMC10325004 DOI: 10.1093/europace/euad157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/10/2023] [Indexed: 07/08/2023] Open
Abstract
AIMS High precordial leads (HPL) on the resting electrocardiogram (ECG) are widely used to improve diagnostic detection of type 1 Brugada ECG pattern (Br1ECGp). A parasympathetic activation marks the initial recovery phase of treadmill stress testing (TET), and this can be useful for detecting the typical ECG pattern. Our study aimed to evaluate the role of a new HPL-treadmill exercise testing (TET) protocol in detecting Br1ECGp fluctuation compared to resting HPL-ECG. METHODS AND RESULTS 74 out of 163 patients of a Brugada syndrome (BrS) Brazilian cohort (GenBra Registry) underwent exercise testing with HPL-TET protocol. Precordial leads were displayed in strategic positions in the right and left parasternal spaces. The step-by-step analysis included ECG classification (as presence or absence of Br1ECGp) in standard vs. HPL leads placement in the following sequences: resting phase, maximal exercise, and the passive recovery phase (including 'quick lay down'). For heart rate recovery (HRR) measurements and comparisons, a Student's t-test was applied. McNemar tests compared the detection of Br1ECGp. The significance level was defined as P < 0.05. Fifty-seven patients (57/74; 77%) were male, the mean age was 49.0 ± 14, 78.4% had spontaneous BrS, and the mean Shanghai score was 4.5. The HPL-TET protocol increased Br1ECGp detection by 32.4% against resting HPL-ECG (52.7% vs. 20.3%, P = 0.001) alone. CONCLUSION Stress testing using HPL with the passive recovery phase in the supine position offers an opportunity to unmask the type 1 Br1ECGp, which could increase the diagnostic yield in this population.
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Affiliation(s)
- Nemer L Pichara
- Departament of Ergometry—Instituto do Coracao (Incor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil - 05403-900
| | - Luciana Sacilotto
- Arrhythmia Unit—Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, 44 AB, CEP 05403-900 Sao Paulo, Brazil
| | - Maurício I Scanavacca
- Arrhythmia Unit—Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, 44 AB, CEP 05403-900 Sao Paulo, Brazil
| | - Acácio Fernandes Cardoso
- Electrocardiology Service, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil - 05403-900
| | - Beatriz Moreira Ayub Ferreira Soares
- Departament of Ergometry—Instituto do Coracao (Incor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil - 05403-900
| | - Paola P PN F Falcochio
- Departament of Ergometry—Instituto do Coracao (Incor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil - 05403-900
| | - Andrea M G Falcão
- Departament of Ergometry—Instituto do Coracao (Incor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil - 05403-900
| | - Natalia Olivetti
- Laboratory of Genetics and Molecular Cardiology (LGMC) Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil - 05403-900
| | - Francisco Carlos da Costa Darrieux
- Arrhythmia Unit—Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Eneas de Carvalho Aguiar, 44 AB, CEP 05403-900 Sao Paulo, Brazil
| | - William A Chalela
- Departament of Ergometry—Instituto do Coracao (Incor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil - 05403-900
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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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5
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Abstract
Exercise stress testing (EST) is indicated for diagnostic and prognostic purposes in the general population. In athletes, stress tests can also be useful to inform the risk of high-intensity training and competition, to assess athletic conditioning, and to refine training regimens. Many specific indications for EST are unique to athletes. Treadmill and cycle ergometer protocols each have their strengths and disadvantages; extensive protocol customization may be necessary to answer the clinical question at hand. A comprehensive understanding of the available tools for exercise testing, their strengths, and their limitations is crucial to providing cardiovascular care to athletic individuals.
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Affiliation(s)
- Gary Parizher
- Sports Cardiology Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael S Emery
- Sports Cardiology Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA.
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6
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Hasdemir C, Sahin H, Duran G, Orman MN, Kocabas U, Payzin S, Aydin M, Antzelevitch C. Electrocardiographic variables associated with underlying Brugada syndrome or drug-induced Type 1 Brugada pattern in patients with slow/fast atrioventricular nodal reentrant tachycardia. J Arrhythm 2022; 38:633-641. [PMID: 35936048 PMCID: PMC9347205 DOI: 10.1002/joa3.12729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/28/2022] [Accepted: 04/21/2022] [Indexed: 12/04/2022] Open
Abstract
Background The coexistence of clinical atrioventricular nodal reentrant tachycardia (AVNRT) and drug-induced type 1 Brugada pattern (DI-Type 1 BrP) has been previously reported. The present study was designed to determine the 12-lead ECG characteristics at baseline and during AVNRT and to identify a subset of 12-lead ECG variables of benefit associated with underlying Brugada syndrome (BrS)/DI-Type 1 BrP among patients with slow/fast AVNRT. Methods A total of 40 (11 numerical/29 categorical) 12-lead ECG parameters were analyzed and compared between patients with (n = 69) and without (n = 104) BrS/DI-Type1-BrP matched for age, female gender, body mass index, left ventricular ejection fraction and comorbid conditions. Five distinct types of ECG pattern (Type A/B/C/D/E) in V1-V2 leads during AVNRT were defined. Results A total of nine electrocardiographic variables, four at baseline, and five during AVNRT were identified. At baseline, patients with BrS/DI-Type 1 BrP had higher prevalence of interatrial block, leftward shift of frontal plane QRS axis, the absence of normal QRS pattern (the presence of rSr' pattern or type 2/3 Brugada pattern) in V1-V2 and QRS fragmentation in inferior leads compared to patients without BrS/DI-Type 1 BrP. During AVNRT, patients with BrS/DI-Type 1 BrP had higher prevalence of Type A ECG pattern ("coved-type" ST-segment elevation) in V1-V2, Type C ECG pattern (pseudo-r' deflection in V1 and "RBBB-like" pattern in V2), pseudo-r' deflection in V1, QRS fragmentation in inferior leads and "isolated" QRS fragmentation/notching/slurring in aVL compared to patients without BrS/DI-Type 1 BrP. Conclusions We identify several electrocardiographic variables that point to an underlying type 1 BrP among patients with slow/fast AVNRT.
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Affiliation(s)
- Can Hasdemir
- Department of CardiologyEge University School of MedicineIzmirTurkey
| | - Hatice Sahin
- Department of CardiologyEge University School of MedicineIzmirTurkey
| | - Gulten Duran
- Department of CardiologyEge University School of MedicineIzmirTurkey
| | - Mehmet N. Orman
- Department of Biostatistics and Medical InformaticsEge University School of MedicineIzmirTurkey
| | - Umut Kocabas
- Department of CardiologyBaskent University Izmir HospitalIzmirTurkey
| | - Serdar Payzin
- Department of CardiologyEge University School of MedicineIzmirTurkey
| | - Mehmet Aydin
- Tepecik Teaching and Research HospitalIzmirTurkey
| | - Charles Antzelevitch
- Lankenau Institute for Medical ResearchWynnewoodPennsylvaniaUSA,Lankenau Heart InstituteWynnewoodPennsylvaniaUSA,Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
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7
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de Andrade AT, Barbosa-Barros R, Nikus K, Raimundo RD, de Abreu LC, Sacilotto L, Darriuex FCC, Yanowitz FG, Brugada P, Pérez-Riera AR. Transient ascending ST-segment depression and widening of the S wave in 3-channel Holter monitoring-A sign of dromotropic disturbance in the right ventricular outflow tract in the Brugada syndrome: A report of five cases. Ann Noninvasive Electrocardiol 2021; 27:e12917. [PMID: 34882891 PMCID: PMC8916569 DOI: 10.1111/anec.12917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/12/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Brugada syndrome (BrS) is somewhat a challenging diagnosis, due to its dynamic pattern. One of the aspects of this disease is a significant conduction disorder located in the right ventricular outflow tract (RVOT), which can be explained as a consequence of low expression of Connexin-43. This decreased conduction speed is responsible for the typical electrocardiographic pattern. Opposite leads located preferably in inferior leads of the electrocardiogram may show a deep and widened S wave associated with ascending ST segment depression. Holter monitoring electrocardiographic (ECG) aspects is still a new frontier of knowledge in BrS, especially in intermittent clinical presentations. METHODS We describe, as an exploratory analysis, five case series of intermittent type 1 BrS to demonstrate the appearance of ascending ST segment depression and widening of the S wave, during 3-channel 24h-Holter monitoring (C1, C2 and C3) with bipolar leads. RESULTS In the five cases described, the ST segment depression was observed mainly in C2, but in some cases also in C1 and C3. Only case 1 presented concomitant intermittent elevation of the ST segment in C1. All cases were intermittent. CONCLUSION The recognition of an ECG pattern with ascending ST-segment depression and widening of the S wave in 3-channel Holter described in this case series should raise a suspicion of the BrS and suggests the counterpart of a dromotropic disturbance registered in the RVOT and/or reciprocal changes.
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Affiliation(s)
| | | | - Kjell Nikus
- Heart Center, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Rodrigo D Raimundo
- Laboratório de Delineamento de Estudos e Escrita Científica, Centro Universitário FMABC, Centro Universitário FMABC, Santo André, Brazil
| | - Luiz C de Abreu
- Laboratório de Delineamento de Estudos e Escrita Científica, Centro Universitário FMABC, Centro Universitário FMABC, Santo André, Brazil.,Universidade Federal do Espírito Santo, Departamento de Educação Integrada em Saúde, UFES, Vitória, Brazil
| | - Luciana Sacilotto
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Francisco C C Darriuex
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Frank G Yanowitz
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Pedro Brugada
- University Hospital of Brussel (UZ Brussel-VUB), Jette, Belgium
| | - Andrés Ricardo Pérez-Riera
- Laboratório de Delineamento de Estudos e Escrita Científica, Centro Universitário FMABC, Centro Universitário FMABC, Santo André, Brazil
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8
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Zou G, Khanna M, Zahid S, Dengle S, Matta B, Zaheer H, Farrell M, Stein R. Ventricular fibrillation arrest due to Brugada syndrome in a coronavirus disease 2019 patient with negative procainamide challenge: a case report. Eur Heart J Case Rep 2021; 5:ytab454. [PMID: 34909573 PMCID: PMC8664766 DOI: 10.1093/ehjcr/ytab454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/05/2021] [Accepted: 10/25/2021] [Indexed: 11/12/2022]
Abstract
Background Pharmacologic challenge test is often used to diagnose Brugada syndrome (BrS) when spontaneous electrocardiograms (ECG) do not show type I Brugada pattern but reported sensitivity varies. The role of the exercise stress test in diagnosing Brugada syndrome is not well-established. Case summary A patient had a type I Brugada pattern ECG during the recovery phase of exercise stress test but had a negative procainamide challenge test. He had a loop recorder implanted and later survived a ventricular fibrillation (VF) arrest provoked by coronavirus disease 2019 (COVID-19). Electrocardiogram on arrival showed type 1 Brugada pattern. He was discharged after implantable cardioverter-defibrillator implantation. He later underwent genetic testing and was found to be heterozygous for c.844C>G (p.Arg282Gly) mutation in the SCN5A gene. Discussion Type 1 Brugada pattern ECG may be unmasked by ST-segment augmentation during recovery from exercise. Exercise stress test may play a role in the diagnosis of Brugada syndrome when suspicion for Brugada syndrome remains after a negative procainamide challenge test or if the patient has exercise-related symptoms. COVID-19 can unmask BrS and trigger a VF cardiac arrest.
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Affiliation(s)
- Guangchen Zou
- Department of Internal Medicine, Danbury Hospital, 24 Hospital Avenue, Danbury, CT 06810, USA
- Department of Medicine, University of Vermont, Burlington, VT, USA
| | - Mukul Khanna
- Department of Cardiology, Danbury Hospital, Danbury, CT, USA
| | - Saliha Zahid
- Department of Internal Medicine, Danbury Hospital, 24 Hospital Avenue, Danbury, CT 06810, USA
- Department of Medicine, University of Vermont, Burlington, VT, USA
| | - Samir Dengle
- Department of Cardiology, Danbury Hospital, Danbury, CT, USA
| | - Bhavna Matta
- Department of Internal Medicine, Danbury Hospital, 24 Hospital Avenue, Danbury, CT 06810, USA
- Department of Medicine, University of Vermont, Burlington, VT, USA
| | - Haris Zaheer
- Department of Internal Medicine, Danbury Hospital, 24 Hospital Avenue, Danbury, CT 06810, USA
- Department of Medicine, University of Vermont, Burlington, VT, USA
| | | | - Russell Stein
- Department of Cardiology, Danbury Hospital, Danbury, CT, USA
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9
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Romero D, Calvo M, Le Rolle V, Béhar N, Mabo P, Hernández A. Multivariate ensemble classification for the prediction of symptoms in patients with Brugada syndrome. Med Biol Eng Comput 2021; 60:81-94. [PMID: 34709544 DOI: 10.1007/s11517-021-02448-1] [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: 09/30/2020] [Accepted: 09/18/2021] [Indexed: 10/20/2022]
Abstract
Identification of asymptomatic patients at higher risk for suffering cardiac events remains controversial and challenging in Brugada syndrome (BS). In this work, we proposed an ECG-based classifier to predict BS-related symptoms, by merging the most predictive electrophysiological features derived from the ventricular depolarization and repolarization periods, along with autonomic-related markers. The initial feature space included local and dynamic ECG markers, assessed during a physical exercise test performed in 110 BS patients (25 symptomatic). Morphological, temporal and spatial properties quantifying the ECG dynamic response to exercise and recovery were considered. Our model was obtained by proposing a two-stage feature selection process that combined a resampled-based regularization approach with a wrapper model assessment for balancing, simplicity and performance. For the classification step, an ensemble was constructed by several logistic regression base classifiers, whose outputs were fused using a performance-based weighted average. The most relevant predictors corresponded to the repolarization interval, followed by two autonomic markers and two other makers of depolarization dynamics. Our classifier allowed for the identification of novel symptom-related markers from autonomic and dynamic ECG responses during exercise testing, suggesting the need for multifactorial risk stratification approaches in order to predict future cardiac events in asymptomatic BS patients. Graphical abstract Pipeline for feature selection and predictive modeling of symptoms in Brugada syndrome.
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Affiliation(s)
- Daniel Romero
- Institute for Bioengineering of Catalonia (IBEC), Campus Besòs EEBE-UPC, Ave. E. Maristany 16, Building C, L5.3, Barcelona, E-08019, Spain
| | - Mireia Calvo
- Institute for Bioengineering of Catalonia (IBEC), Campus Besòs EEBE-UPC, Ave. E. Maristany 16, Building C, L5.3, Barcelona, E-08019, Spain
| | - Virginie Le Rolle
- CHU Rennes, Inserm, University of Rennes, LTSI - UMR 1099, F-35000, Rennes, France
| | - Nathalie Béhar
- CHU Rennes, Inserm, University of Rennes, LTSI - UMR 1099, F-35000, Rennes, France
| | - Phillipe Mabo
- CHU Rennes, Inserm, University of Rennes, LTSI - UMR 1099, F-35000, Rennes, France
| | - Alfredo Hernández
- CHU Rennes, Inserm, University of Rennes, LTSI - UMR 1099, F-35000, Rennes, France.
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10
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Long-Term Prognosis of Febrile Individuals with Right Precordial Coved-Type ST-Segment Elevation Brugada Pattern: A 10-Year Prospective Follow-Up Study. J Clin Med 2021; 10:jcm10214997. [PMID: 34768515 PMCID: PMC8584636 DOI: 10.3390/jcm10214997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 11/16/2022] Open
Abstract
A febrile state may provoke a Brugada electrocardiogram (ECG) pattern and trigger ventricular tachyarrhythmias in susceptible individuals. However, the prognostic value of fever-induced Brugada ECG pattern remains unclear. We analyzed the clinical and extended long-term follow-up data of consecutive febrile patients with a type 1 Brugada ECG presented to the emergency department. A total of 21 individuals (18 males; mean age, 43.7 ± 18.6 years at diagnosis) were divided into symptomatic (resuscitated cardiac arrest in one, syncope in two) and asymptomatic (18, 86%) groups. Sustained polymorphic ventricular tachycardias were inducible in two patients with previous syncope. All 18 asymptomatic patients had no spontaneous type 1 Brugada ECG recorded at second intercostal space and no family history of sudden death. Among asymptomatic individuals, 4 had a total 12 of repeated non-arrhythmogenic febrile episodes all with recurrent type 1 Brugada ECGs, and none had a ventricular arrhythmic event during 116 ± 19 months of follow-up. In the symptomatic group, two had defibrillator shocks for a new arrhythmic event at 31- and 49 months follow-up, respectively, and one without defibrillator therapy died suddenly at 8 months follow-up. A previous history of aborted sudden death or syncope was significantly associated with adverse outcomes in symptomatic compared with asymptomatic individuals (log-rank p < 0.0001). In conclusion, clinical presentation or history of syncope is the most important parameter in the risk stratification of febrile patients with type 1 Brugada ECG. Asymptomatic individuals with a negative family history of sudden death and without spontaneous type 1 Brugada ECG, have an exceptionally low future risk of arrhythmic events. Careful follow-up with timely and aggressive control of fever is an appropriate management option.
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11
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Abstract
Brugada syndrome (BrS) is an inherited cardiac arrhythmia syndrome that causes a heightened risk for ventricular tachyarrhythmias and sudden cardiac death. BrS is characterised by a coved ST-segment elevation in right precordial leads. The prevalence is estimated to range between 1 in 5,000 to 1 in 2,000 in different populations, with the highest being in Southeast Asia and in males. More than 18 genes associated with BrS have been discovered and recent evidence has suggested a complex polygenic mode of inheritance with multiple common and rare genetic variants acting in concert to produce the BrS phenotype. Diagnosis of BrS in patients currently relies on presentation with a type-1 Brugada pattern on ECG either spontaneously or following a drug provocation test using a sodium channel blocker. Risk assessment in patients diagnosed with BrS is controversial, especially with regard to the predictive value of programmed electrical stimulation and novel ECG parameters, such as QRS fragmentation. The first line of BrS therapy remains an implantable cardioverter defibrillator (ICD), although radiofrequency catheter ablation has been shown to be an effective option in patients with contraindications for an ICD. True BrS can be unmasked on ECG in susceptible individuals by monitoring factors such as fever, and this has been recently evident in several patients infected with the 2019 novel coronavirus (COVID-19). Aggressive antipyretic therapy and regular ECG monitoring until fever resolves are current recommendations to help reduce the arrhythmic risk in these COVID-19 patients. In this review, we summarise the current knowledge on the epidemiology, pathophysiology, genetics, clinical diagnosis, risk stratification and treatment of patients with BrS, with special emphasis on COVID-19 comorbidity.
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Affiliation(s)
| | - Giridhar Korlipara
- Cardiology Division of Department of Medicine, Renaissance School of Medicine, Stony Brook Medical Center, Stony Brook, NY, USA
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12
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Leong KMW, Ng FS, Shun-Shin MJ, Koa-Wing M, Qureshi N, Whinnett ZI, Linton NF, Lefroy D, Francis DP, Harding SE, Davies DW, Peter NS, Lim PB, Behr E, Lambiase PD, Varnava A, Kanagaratnam P. Non-invasive detection of exercise-induced cardiac conduction abnormalities in sudden cardiac death survivors in the inherited cardiac conditions. Europace 2021; 23:305-312. [PMID: 33083839 DOI: 10.1093/europace/euaa248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 08/18/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Rate adaptation of the action potential ensures spatial heterogeneities in conduction across the myocardium are minimized at different heart rates providing a protective mechanism against ventricular fibrillation (VF) and sudden cardiac death (SCD), which can be quantified by the ventricular conduction stability (V-CoS) test previously described. We tested the hypothesis that patients with a history of aborted SCD due to an underlying channelopathy or cardiomyopathy have a reduced capacity to maintain uniform activation following exercise. METHODS AND RESULTS Sixty individuals, with (n = 28) and without (n = 32) previous aborted-SCD event underwent electro-cardiographic imaging recordings following exercise treadmill test. These included 25 Brugada syndrome, 13 hypertrophic cardiomyopathy, 12 idiopathic VF, and 10 healthy controls. Data were inputted into the V-CoS programme to calculate a V-CoS score that indicate the percentage of ventricle that showed no significant change in ventricular activation, with a lower score indicating the development of greater conduction heterogeneity. The SCD group, compared to those without, had a lower median (interquartile range) V-CoS score at peak exertion [92.8% (89.8-96.3%) vs. 97.3% (94.9-99.1%); P < 0.01] and 2 min into recovery [95.2% (91.1-97.2%) vs. 98.9% (96.9-99.5%); P < 0.01]. No significant difference was observable later into recovery at 5 or 10 min. Using the lowest median V-CoS scores obtained during the entire recovery period post-exertion, SCD survivors had a significantly lower score than those without for each of the different underlying aetiologies. CONCLUSION Data from this pilot study demonstrate the potential use of this technique in risk stratification for the inherited cardiac conditions.
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Affiliation(s)
- Kevin Ming Wei Leong
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Fu Siong Ng
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Matthew J Shun-Shin
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Michael Koa-Wing
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Norman Qureshi
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Zachary I Whinnett
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Nick F Linton
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - David Lefroy
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Darrel P Francis
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Sian E Harding
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - D Wyn Davies
- Imperial College Healthcare NHS Trust, London, UK
| | - Nicholas S Peter
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Phang Boon Lim
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Elijah Behr
- St George's University Hospitals NHS Trust, London, UK
| | | | - Amanda Varnava
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Prapa Kanagaratnam
- Institute of Cardiovascular Science, University College London & Bart's Heart Centre, Bart's Health NHS Trust, London, UK.,Imperial College Healthcare NHS Trust, London, UK
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13
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Heidbuchel H, Arbelo E, D'Ascenzi F, Borjesson M, Boveda S, Castelletti S, Miljoen H, Mont L, Niebauer J, Papadakis M, Pelliccia A, Saenen J, Sanz de la Garza M, Schwartz PJ, Sharma S, Zeppenfeld K, Corrado D. Recommendations for participation in leisure-time physical activity and competitive sports of patients with arrhythmias and potentially arrhythmogenic conditions. Part 2: ventricular arrhythmias, channelopathies, and implantable defibrillators. Europace 2021; 23:147-148. [PMID: 32596731 DOI: 10.1093/europace/euaa106] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This paper belongs to a series of recommendation documents for participation in leisure-time physical activity and competitive sports by the European Association of Preventive Cardiology (EAPC). Together with an accompanying paper on supraventricular arrhythmias, this second text deals specifically with those participants in whom some form of ventricular rhythm disorder is documented, who are diagnosed with an inherited arrhythmogenic condition, and/or who have an implanted pacemaker or cardioverter defibrillator. A companion text on recommendations in athletes with supraventricular arrhythmias is published in the European Journal of Preventive Cardiology. Since both texts focus on arrhythmias, they are the result of a collaboration between EAPC and the European Heart Rhythm Association (EHRA). The documents provide a framework for evaluating eligibility to perform sports, based on three elements, i.e. the prognostic risk of the arrhythmias when performing sports, the symptomatic impact of arrhythmias while performing sports, and the potential progression of underlying structural problems as the result of sports.
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Affiliation(s)
- Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp, University Antwerp, Wilrijkstraat 10, 2650 Antwerp, Belgium
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Flavio D'Ascenzi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Mats Borjesson
- Centre for Health and Performance (CHP), Department of Food, Nutrition and Sport Sciences, Gothenburg University, Sweden.,Department of Neuroscience and Physiology, Gothenburg University, Gothenburg, Sweden
| | - Serge Boveda
- Cardiology Department, Clinique Pasteur, 45 Avenue de Lombez, 31076 Toulouse, France
| | - Silvia Castelletti
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Laboratory of Cardiovascular Genetics, Milan, Italy
| | - Hielko Miljoen
- Department of Cardiology, University Hospital Antwerp, University Antwerp, Wilrijkstraat 10, 2650 Antwerp, Belgium
| | - Lluis Mont
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Josef Niebauer
- Institute of Sports Medicine, Prevention and Rehabilitation, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Michael Papadakis
- Cardiology Clinical Academic Group, St. George's University of London, London, UK.,St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Antonio Pelliccia
- National Institute of Sports Medicine, Italian National Olympic Committee, Via dei Campi Sportivi 46, Rome, Italy
| | - Johan Saenen
- Department of Cardiology, University Hospital Antwerp, University Antwerp, Wilrijkstraat 10, 2650 Antwerp, Belgium
| | | | - Peter J Schwartz
- Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Laboratory of Cardiovascular Genetics, Milan, Italy
| | - Sanjay Sharma
- Cardiology Clinical Academic Group, St. George's University of London, London, UK.,St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Domenico Corrado
- Department of Cardiology, University of Padova, Padova, Italy.,Department of Pathology, University of Padova, Padova, Italy
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14
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Maury P, Delasnerie H, Beneyto M, Rollin A. Autonomic cardiac innervation: impact on the evolution of arrhythmias in inherited cardiac arrhythmia syndromes. Herzschrittmacherther Elektrophysiol 2021; 32:308-314. [PMID: 34185133 DOI: 10.1007/s00399-021-00774-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/17/2021] [Indexed: 11/28/2022]
Abstract
The autonomic nervous system (ANS) is an essential component of arrhythmogenicity, especially in the absence of structural heart disease and channelopathy. In this article, the authors review the role and characteristics of ANS in various channelopathies. Some of these, such as most long QT syndromes and catecholaminergic polymorphic ventricular tachycardia, are highly dependent on sympathetic activation, while parasympathetic tone is an important factor for arrhythmias in other channelopathies such as Brugada syndrome or early repolarisation syndrome. Recent advances highlighting the subtle role of ANS in channelopathies are presented here, demonstrating that all is far from being so simple and straightforward and revealing some paradoxical behaviours of channelopathies in relation to discrete ANS imbalance.
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Affiliation(s)
- Philippe Maury
- Department of Cardiology, University Hospital Rangueil, Toulouse, France. .,I2MC, INSERM UMR 1297, Toulouse, France.
| | - Hubert Delasnerie
- Department of Cardiology, University Hospital Rangueil, Toulouse, France
| | - Maxime Beneyto
- Department of Cardiology, University Hospital Rangueil, Toulouse, France
| | - Anne Rollin
- Department of Cardiology, University Hospital Rangueil, Toulouse, France
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15
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Elgara M, Khalil MO, Raza T. Hyperthyroidism precipitating cardiac arrest in a patient with Brugada pattern. BMJ Case Rep 2021; 14:14/4/e240038. [PMID: 33858885 PMCID: PMC8054039 DOI: 10.1136/bcr-2020-240038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A 38-year-old man previously healthy suffered an out-of-hospital cardiac arrest; he was resuscitated successfully and admitted to the intensive care unit. His initial ECG suggested a Brugada pattern; other laboratory tests revealed low potassium level, low Thyroid Stimulating Hormone (TSH) and high FT4. He was started on carbimazole for hyperthyroidism, along with other supportive care. A comprehensive cardiac evaluation was done, including ajmaline and flecainide tests, results were inconclusive. An implantable cardioverter defibrillator device (ICD) was inserted to prevent such catastrophic events in the future. After discharge and on follow-up, our patient was doing well. His thyroid function test (TFT) was normal; moreover, a follow-up ICD interrogation did not record any arrhythmias. This case report highlighted asymptomatic hyperthyroidism as a precipitant for Brugada pattern resulting in sudden cardiac arrest.
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Affiliation(s)
- Mohamed Elgara
- Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Tasleem Raza
- Critical care, Hamad Medical Corporation, Doha, Qatar
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16
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Morita H, Asada ST, Miyamoto M, Morimoto Y, Kimura T, Mizuno T, Nakagawa K, Watanabe A, Nishii N, Ito H. Significance of Exercise-Related Ventricular Arrhythmias in Patients With Brugada Syndrome. J Am Heart Assoc 2020; 9:e016907. [PMID: 33222599 PMCID: PMC7763771 DOI: 10.1161/jaha.120.016907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Sinus tachycardia during exercise attenuates ST‐segment elevation in patients with Brugada syndrome, whereas ST‐segment augmentation after an exercise test is a high‐risk sign. Some patients have premature ventricular contractions (PVCs) related to exercise, but the significance of exercise‐related PVCs in patients with Brugada syndrome is still unknown. The objective of this study was to determine the significance of exercise‐related PVCs for predicting occurrence of ventricular fibrillation (VF) in patients with Brugada syndrome. Methods and Results The subjects were 307 patients with Brugada syndrome who performed a treadmill exercise test. We evaluated the occurrence of PVCs at rest, during exercise and at the peak of exercise, and during recovery after exercise (0–5 minutes). We followed the patients for 92±68 months and evaluated the occurrence of VF. PVCs occurred in 82 patients (27%) at the time of treadmill exercise test: PVCs appeared at rest in 14 patients (4%), during exercise in 60 patients (20%), immediately after exercise (0–1.5 minutes) in 28 patients (9%), early after exercise (1.5–3 minutes) in 18 patients (6%), and late after exercise (3–5 minutes) in 12 patients (4%). Thirty patients experienced VF during follow‐up. Multivariable analysis including symptoms, spontaneous type 1 ECG, and PVCs in the early recovery phase showed that these factors were independently associated with VF events during follow‐up. Conclusions PVCs early after an exercise test are associated with future occurrence of VF events. Rebound of vagal nerve activity at the early recovery phase would promote ST‐segment augmentation and PVCs in high‐risk patients with Brugada syndrome.
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Affiliation(s)
- Hiroshi Morita
- Department of Cardiovascular Therapeutics Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Saori T Asada
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Masakazu Miyamoto
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Yoshimasa Morimoto
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Tomonari Kimura
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Tomofumi Mizuno
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
| | - Nobuhiro Nishii
- Department of Cardiovascular Therapeutics Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine Okayama University Graduate School of Medicine and Dentistry Okayama Japan
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17
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Rizzo A, Borio G, Sieira J, Van Dooren S, Overeinder I, Bala G, Pappaert G, Maj R, Osório TG, Terasawa M, Galli A, Cecchini F, Miraglia V, Ströker E, La Meir M, Brugada P, Chierchia GB, de Asmundis C. Ajmaline Testing and the Brugada Syndrome. Am J Cardiol 2020; 135:91-98. [PMID: 32861732 DOI: 10.1016/j.amjcard.2020.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/21/2020] [Accepted: 08/24/2020] [Indexed: 12/22/2022]
Abstract
Brugada syndrome (BrS) diagnosis requires the presence of a typical type 1 ECG pattern. Owing to the spontaneous ECG variability, the real BrS prevalence in the general population remains unclear. The aim of the present study was to evaluate the prevalence of positive ajmaline challenge for BrS in a cohort of consecutive patients who underwent electrophysiological evaluation for different clinical reasons. All consecutive patients from 2008 to 2019 who underwent ajmaline testing were prospectively included. A total of 2,456 patients underwent ajmaline testing, 742 (30.2%) in the context of familial screening for BrS. In non-familial screening group (1,714) ajmaline testing resulted positive in 186 (10.9%). Indications for ajmaline testing were: suspicious BrS ECG in 23 cases (12.4%), palpitations in 27 (14.5%), syncope in 71 (38.2%), presyncope in 7 (3.8%), family history of sudden cardiac death in 18 (9.7%), documented ventricular arrhythmias in 12 (6.5%), unexplained cardiac arrest in 4 (2.2%), atrial fibrillation in 16 (8.5%), brady-arrhythmias in 1 (0.5%), and cerebrovascular accidents in 7 (3.7%). Compared with the overall population, ajmaline testing positive patients were younger (42.8 ± 15.5 vs 48.9 ± 20.4; p <0.001) and more frequently male (65.1% vs 56.3%; p = 0.023). Implantable cardioverter defibrillator was implanted in 84 patients (45.2%). During a median follow-up of 42.4 months, 12 appropriate shocks and 13 implantable cardioverter defibrillator related complications were reported. In conclusion, the BrS was diagnosed in an unexpected high proportion of patients that underwent ajmaline testing for a variety of cardiovascular symptoms. This can lead to an adequate counseling and clinical management in BrS patients.
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18
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Abela M, Sharma S. Electrocardiographic interpretation in athletes. Minerva Cardiol Angiol 2020; 69:533-556. [PMID: 33059398 DOI: 10.23736/s2724-5683.20.05331-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Participation in regular exercise of moderate intensity is associated with a plethora of systemic benefits, including a reduction in risk factors for coronary atherosclerosis; however, intensive exercise may paradoxically culminate in sudden cardiac arrest among individuals harboring arrhythmogenic substrates. The precise mechanism for arrhythmogenesis is likely multifactorial, however, surges in catecholamines, electrolyte shifts, acid-base disturbances, increased core temperature and demand myocardial ischemia are potential contributors. Although most deaths occur in middle aged and older males with atherosclerotic coronary artery disease, a significant proportion also affect young athletes with inherited or congenital cardiac abnormalities. The impact of such catastrophes on society, particularly when a young high-profile athlete is affected could be considered a justified reason for identifying individuals who may be at risk. Given the rarity of deaths in young athletes, only the simplest screening test, such as the 12-lead electrocardiography (ECG) may be considered to be cost effective. The ECG is effective for detecting serious electrical diseases in young athletes such as congenital electrical accessory pathways and ion channel diseases but can also identify athletes with potential life-threatening structural diseases such as hypertrophic and arrhythmogenic cardiomyopathy. One of the concerns about ECG screening is that regular intensive exercise results in several physiological alterations in cardiac structure and function that are reflected on the athlete's ECG. Sinus bradycardia, first-degree atrioventricular block, incomplete right bundle branch block, minor J-point elevation and large QRS voltages are common. Conversely, some repolarization anomalies affecting the ST segment, T waves and QT interval may overlap with patterns observed in patients with serious cardiac diseases. The situation is complicated further because age, sex and ethnicity of the athletes also influence the ECG and there is a risk that erroneous interpretation could have serious consequences. This review will describe the normal electrical patterns of the "athlete's heart" and provide insights into differentiation physiological electrical patterns from those observed in serious cardiac disease.
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Affiliation(s)
- Mark Abela
- Department of Cardiology, Mater Dei Hospital, Msida, Malta - .,Malta Medical School, University of Malta, Msida, Malta - .,St. George's University Hospitals, NHS Foundation Trust, St George's University, London, UK -
| | - Sanjay Sharma
- St. George's University Hospitals, NHS Foundation Trust, St George's University, London, UK
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19
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Abstract
The main inherited cardiac arrhythmias are long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia and Brugada syndrome. These rare diseases are often the underlying cause of sudden cardiac death in young individuals and result from mutations in several genes encoding ion channels or proteins involved in their regulation. The genetic defects lead to alterations in the ionic currents that determine the morphology and duration of the cardiac action potential, and individuals with these disorders often present with syncope or a life-threatening arrhythmic episode. The diagnosis is based on clinical presentation and history, the characteristics of the electrocardiographic recording at rest and during exercise and genetic analyses. Management relies on pharmacological therapy, mostly β-adrenergic receptor blockers (specifically, propranolol and nadolol) and sodium and transient outward current blockers (such as quinidine), or surgical interventions, including left cardiac sympathetic denervation and implantation of a cardioverter-defibrillator. All these arrhythmias are potentially life-threatening and have substantial negative effects on the quality of life of patients. Future research should focus on the identification of genes associated with the diseases and other risk factors, improved risk stratification and, in particular for Brugada syndrome, effective therapies.
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20
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Arias MA, Pachón M, Brugada P. The Hidden Reveals the Hidden. Circulation 2020; 141:1200-1204. [PMID: 32250700 DOI: 10.1161/circulationaha.120.045683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Miguel A Arias
- Arrhythmia Unit, Department of Cardiology, Complejo Hospitalario Universitario de Toledo, Spain (M.A.A., M.P.)
| | - Marta Pachón
- Arrhythmia Unit, Department of Cardiology, Complejo Hospitalario Universitario de Toledo, Spain (M.A.A., M.P.)
| | - Pedro Brugada
- Cardiovascular Division, Free University of Brussels (UZ Brussel), Belgium (P.B.)
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21
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Romero D, Behar N, Petit B, Probst V, Sacher F, Mabo P, Hernández AI. Dynamic changes in ventricular depolarization during exercise in patients with Brugada syndrome. PLoS One 2020; 15:e0229078. [PMID: 32126115 PMCID: PMC7053736 DOI: 10.1371/journal.pone.0229078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 01/29/2020] [Indexed: 11/18/2022] Open
Abstract
Brugada syndrome (BS) is a genetic pathological condition associated with a high risk for sudden cardiac death (SCD). Ventricular depolarization disorders have been suggested as a potential electrophysiological mechanism associated with high SCD risk on patients with BS. This paper aims to characterize the dynamic changes of ventricular depolarization observed during physical exercise in symptomatic and asymptomatic BS patients. To this end, cardiac ventricular depolarization features were automatically extracted from 12-lead ECG recordings acquired during standardized exercise stress test in 110 BS patients, of whom 25 were symptomatic. Conventional parameters were evaluated, including QRS duration, R and S wave amplitudes ( AR, AS), as well as QRS morphological features, such as up-stroke and down-stroke slopes of the R and S waves ( UR, DR and US). The effects of physical exercise and recovery on the dynamics of these markers were assessed in both BS populations. Features showing significantly different dynamics between the studied groups were used alone and in combination with the clinical characteristics of the patients in a logistic regression analysis. Results show larger changes in the second half of the QRS complex through AS and US measured in the right precordial leads for asymptomatic patients, especially during recovery, when the vagal tone is more pronounced. Multivariate analysis involving both types of features resulted in a reduced model of three relevant features ( ΔAS in lead V2, Sex and heart rate recovery, HRR), which achieved a suitable discrimination performance between groups; sensitivity = 80% and specificity = 75% (AUC = 83%). However, after controlling the model for possible confounding factors, only one feature ( ΔAS) remained meaningful. This adjusted model significantly improved the overall discrimination performance by up to: sensitivity = 84% and specificity = 100% (AUC = 94%). The study highlights the importance of physical exercise test to unmask differentiated behaviors between symptomatic and asymptomatic BS patients through depolarization dynamic analysis. This analysis together with the obtained model may help to identify asymptomatic patients at low or high risk of future cardiac events, but it should be confirmed by further prospective studies.
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Affiliation(s)
- Daniel Romero
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
| | - Nathalie Behar
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
| | - Bertrand Petit
- Service Cardiologie, GH Sud. Saint Pierre La Réunion, Saint-Pierre, France
| | | | | | - Philippe Mabo
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, Rennes, France
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22
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Rizzo A, de Asmundis C, Brugada P, La Meir M, Chierchia GB. Ablation for the treatment of Brugada syndrome: current status and future prospects. Expert Rev Med Devices 2020; 17:123-130. [PMID: 31986921 DOI: 10.1080/17434440.2020.1719831] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Brugada syndrome (BrS) is an inherited disease characterized by an increased risk of sudden cardiac death (SCD). Therapeutic options in symptomatic patients are limited to implantable cardioverter defibrillator (ICD) and quinidine, but catheter ablation of the right ventricular outflow tract (RVOT) offers a potential cure. Different ablation strategies have been used to treat patients with symptomatic Brugada syndrome. Epicardial radiofrequency substrate ablation of the RVOT/right ventricle (RV) has emerged as a promising tool for the management of the disease.Areas covered: The historical management of BrS, endocardial and epicardial ablation techniques, the use of sodium channel blockers (SCB) and complications are summarized here.Expert opinion: Ventricular fibrillation (VF)-triggering premature ventricular contractions (PVCs) in patients with BrS are unpredictable, spontaneous ones are rarely present to be mapped, making this approach impractical. Furthermore, endocardial mapping for BrS substrates does not seem effective due to the epicardial pathological substrate localization. The size variation of the BrS substrate areas during SCB infusion suggests a dynamic process as arrhythmogenic basis and SCB infusion should guide BrS epicardial ablation of all abnormal potentials areas. If BrS epicardial ablation can truly provide long-term prevention of ventricular arrhythmias it may potentially become an alternative to ICD therapy.
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Affiliation(s)
- Alessandro Rizzo
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Pedro Brugada
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Mark La Meir
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Gian-Battista Chierchia
- Heart Rhythm Management Center, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
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23
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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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24
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Nagase S, Kamakura T, Kataoka N, Wada M, Yamagata K, Ishibashi K, Inoue YY, Miyamoto K, Noda T, Aiba T, Izumi C, Noguchi T, Yasuda S, Shimizu W, Kamakura S, Kusano K. Low-Voltage Type 1 ECG Is Associated With Fatal Ventricular Tachyarrhythmia in Brugada Syndrome. J Am Heart Assoc 2019; 7:e009713. [PMID: 30571377 PMCID: PMC6404198 DOI: 10.1161/jaha.118.009713] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Epicardial mapping can reveal low‐voltage areas on the right ventricular outflow tract in patients with Brugada syndrome with several ventricular fibrillation (VF) episodes. A type 1 ECG is associated with an abnormal electrogram on right ventricular outflow tract epicardium. This study investigated the clinical significance of the amplitude of type 1 ECGs in patients with Brugada syndrome. Methods and Results In 209 patients with Brugada syndrome with a spontaneous type 1 ECG (26 resuscitated from VF, 54 with syncope, and 129 asymptomatic), the amplitude of the ECG in leads exhibiting type 1 was measured among V1 to V3 leads positioned in the standard and upper 1 and 2 intercostal spaces. The number of ECG leads exhibiting type 1 did not differ among groups. The averaged amplitude of type 1 ECG was, however, significantly smaller in the group resuscitated from VF than in the asymptomatic group (P<0.05). Moreover, the minimum amplitude of type 1 ECG was significantly smaller in the group resuscitated from VF than in the group with syncope and the asymptomatic group (P<0.05 and P<0.01, respectively). During follow‐up (56±48 months), VF occurred in 29 patients. Kaplan‐Meier analysis revealed that patients with the minimum amplitude of type 1 ECG lower than or at the median value had a higher incidence of VF (log‐rank test, P<0.01). In multivariate analysis, syncope, past VF episode, and minimum amplitude of type 1 ECG ≤0.8 mV were independent predictors of VF events during follow‐up. Conclusions Low‐voltage type 1 ECG is highly and independently related to fatal ventricular tachyarrhythmia in patients with Brugada syndrome.
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Affiliation(s)
- Satoshi Nagase
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Tsukasa Kamakura
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Naoya Kataoka
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Mitsuru Wada
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Kenichiro Yamagata
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Kohei Ishibashi
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Yuko Y Inoue
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Koji Miyamoto
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Takashi Noda
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Takeshi Aiba
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Chisato Izumi
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Teruo Noguchi
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Satoshi Yasuda
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Wataru Shimizu
- 2 Department of Cardiovascular Medicine Nippon Medical School Tokyo Japan
| | - Shiro Kamakura
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Kengo Kusano
- 1 Division of Arrhythmia and Electrophysiology Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
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25
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Wu Q, Hayashi H, Hira D, Sonoda K, Ueshima S, Ohno S, Makiyama T, Terada T, Katsura T, Miura K, Horie M. Genetic variants of alcohol-metabolizing enzymes in Brugada syndrome: Insights into syncope after drinking alcohol. J Arrhythm 2019; 35:752-759. [PMID: 31624517 PMCID: PMC6787161 DOI: 10.1002/joa3.12227] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 07/31/2019] [Accepted: 08/06/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with Brugada syndrome (BrS) are known to have arrhythmic events after alcohol drinking and are recommended to avoid its excessive intake. Mechanisms underlying the alcohol-induced cardiac events are however unknown. This study aimed to test the hypothesis whether activity of alcohol-metabolizing enzymes determines fatal arrhythmic events after drinking alcohol. METHODS A total of 198 Japanese patients with BrS were enrolled in this study. These patients were classified into symptomatic (n = 90) and asymptomatic (n = 108) groups. The former was divided into an alcohol-related group (syncope after alcohol drinking, n = 16) and an alcohol-unrelated group (n = 74). Polymerase chain reaction was performed to determine genetic variants of genes encoding alcohol dehydrogenase 1B (ADH1B) and aldehyde dehydrogenase 2 (ALDH2). RESULTS The genotype distribution for ALDH2 was not significantly different between symptomatic and asymptomatic groups and between alcohol-related and alcohol-unrelated groups. The genotype distribution for ADH1B was not significantly different between symptomatic and asymptomatic groups, but the genotype ADH1B His/His was significantly more prevalent in the alcohol-related group than in the alcohol-unrelated group (81.3% vs 50%, P = .023). In multivariate logistic regression analysis, the genotype of ADH1B His/His was independently associated with syncope after alcohol drinking (odds ratio, 5.746; 95% confidence interval, 1.580-28.421; P = .007). CONCLUSIONS Arrhythmic events after alcohol drinking was associated with enhanced activity of alcohol-metabolizing enzyme ADH1B in our cohort of BrS. Therefore, the lifestyle change to avoid the excessive alcohol intake deserves attention.
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Affiliation(s)
- Qi Wu
- Department of Cardiovascular MedicineShiga University of Medical ScienceOhtsuJapan
| | - Hideki Hayashi
- Department of Cardiovascular MedicineShiga University of Medical ScienceOhtsuJapan
| | - Daiki Hira
- Department of PharmacyShiga University of Medical Science HospitalOhtsuJapan
- College of Pharmaceutical SciencesRitsumeikan UniversityKusatsuJapan
| | - Keiko Sonoda
- Department of Cardiovascular MedicineShiga University of Medical ScienceOhtsuJapan
- Department of Bioscience and GeneticsNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Satoshi Ueshima
- College of Pharmaceutical SciencesRitsumeikan UniversityKusatsuJapan
| | - Seiko Ohno
- Department of Cardiovascular MedicineShiga University of Medical ScienceOhtsuJapan
- Department of Bioscience and GeneticsNational Cerebral and Cardiovascular CenterSuitaJapan
- Center for Epidemiologic Research in AsiaShiga University of Medical ScienceOhtsuJapan
| | - Takeru Makiyama
- Department of Cardiovascular and MedicineKyoto University Graduate School of MedicineKyotoJapan
| | - Tomohiro Terada
- Department of PharmacyShiga University of Medical Science HospitalOhtsuJapan
| | - Toshiya Katsura
- College of Pharmaceutical SciencesRitsumeikan UniversityKusatsuJapan
| | - Katsuyuki Miura
- Center for Epidemiologic Research in AsiaShiga University of Medical ScienceOhtsuJapan
- Department of Public HealthShiga University of Medical ScienceOhtsuJapan
| | - Minoru Horie
- Department of Cardiovascular MedicineShiga University of Medical ScienceOhtsuJapan
- Center for Epidemiologic Research in AsiaShiga University of Medical ScienceOhtsuJapan
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26
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Abstract
Brugada syndrome (BrS) is a hereditary condition that is characterized by ST elevation, ventricular tachycardia or fibrillation, and sudden cardiac death in otherwise healthy patients. Life-threatening arrhythmias generally occur, while at rest, with fever or during vagotonic states. Exercise is generally not considered a trigger for ventricular arrhythmias or syncope in patients with BrS. We describe a patient who presented with exercise-induced syncope, ventricular tachycardia during an exercise test, and was found to be both genotypically and phenotypically positive for BrS. This case highlights a potentially important role of exercise testing in diagnosing and risk stratifying certain patients with BrS.
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Affiliation(s)
- Anjan S Batra
- Department of Pediatric Cardiology, University of California-Irvine and Children's Hospital of Orange County, Orange CA, USA
| | - Rachel Watson
- Department of Pediatrics, University of California-Irvine and Children's Hospital of Orange County, Orange CA, USA
| | - Anthony C McCanta
- Department of Pediatric Cardiology, University of California-Irvine and Children's Hospital of Orange County, Orange CA, USA
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27
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Aghamohammadzadeh R, El-Omar SM, Rowlands D, El-Omar M. ST elevation in recovery post exercise with normal coronary arteries. BMJ Case Rep 2019; 12:12/7/e229766. [PMID: 31289167 DOI: 10.1136/bcr-2019-229766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present the case of a 45-year-old healthy man who successfully completed three stages of the Bruce protocol but developed inferolateral ST segment elevation in the recovery phase. The ECG change was associated with a marked drop in blood pressure. He underwent emergency coronary angiography which revealed normal coronary arteries. It is likely that post-exercise hypotension triggered coronary spasm which caused the ST segment elevation. Alternatively, coronary spasm may have been the primary event, inducing sufficient myocardial ischaemia to cause a marked drop in blood pressure. Exercise tolerance testing is often a reliable test to rule out reversible myocardial ischaemia. While the physician is focused on ischaemic changes or rhythm abnormalities developing during the exercise phase, the recovery period is just as important and requires as much vigilance. Coronary vasospasm can result in significant ST changes and haemodynamic compromise at any point during the test, and the ECG traces can be indistinguishable from a classic ST elevation myocardial infarction, as in the present case.
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Affiliation(s)
| | - Suhaib Magdi El-Omar
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Derek Rowlands
- Manchester Heart Center, Manchester Royal Infirmary, Manchester, UK
| | - Magdi El-Omar
- Manchester Heart Center, Manchester Royal Infirmary, Manchester, UK
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28
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Tijskens M, Heidbuchel H, Sarkozy A. Supranormal heart rate during peak exercise stress test triggering type-1 Brugada ECG pattern. J Cardiovasc Electrophysiol 2019; 30:1367-1368. [PMID: 31077499 DOI: 10.1111/jce.13973] [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: 04/12/2019] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 11/28/2022]
Abstract
We present a remarkable maximal capacity exercise test of a 52-year-old patient diagnosed with Brugada syndrome (BrS). As the patient reaches a supranormal sinus heart rate, the type-1 electrocardiogram pattern of BrS appeared and then disappeared immediately after cessation of exercise.
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Affiliation(s)
- Maxime Tijskens
- Department of Cardiology, University Hospital Antwerp, Edegem, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp, Edegem, Belgium
| | - Andrea Sarkozy
- Department of Cardiology, University Hospital Antwerp, Edegem, Belgium
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29
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Nakagawa E, Naruko T, Makita T. Reproducibility and diagnostic usefulness of repeated sodium channel blocker test at higher precordial electrocardiogram recording in a patient with Brugada syndrome. HeartRhythm Case Rep 2019; 5:251-255. [PMID: 31193222 PMCID: PMC6522474 DOI: 10.1016/j.hrcr.2019.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Eiichiro Nakagawa
- Division of Cardiac Electrophysiology, Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
- Address reprint requests and correspondence: Dr Eiichiro Nakagawa, Division of Cardiac Electrophysiology, Cardiovascular Center, Osaka Red Cross Hospital, 5-30 Fudegasaki-cho, Tennoji-ku, Osaka 543-8555, Japan.
| | - Takahiko Naruko
- Department of Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Toshinori Makita
- Division of Cardiac Electrophysiology, Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
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30
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Iglesias DG, Rubín J, Pérez D, Morís C, Calvo D. Insights for Stratification of Risk in Brugada Syndrome. Eur Cardiol 2019; 14:45-49. [PMID: 31131036 PMCID: PMC6523056 DOI: 10.15420/ecr.2018.31.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Brugada syndrome (BrS) is an inherited disease with an increased risk of sudden cardiac death (SCD). However, testing identifies genetic disorders in only 20-30% of patients analysed, indicating a gap in knowledge of its genetic aetiology. Diagnosis relies on ECG, and risk stratification in BrS patients is challenging, primarily because of the complexity of the issue. As a result, clinicians fail to provide the appropriate strategy for SCD prevention for many patients. Several variables and interventions are being studied to improve diagnostics and maximise patient protection. In addition, the scientific community must increase efforts to provide patient care according to knowledge and research for improving stratification of risk. In this article, the authors summarise contemporary evidence on clinical variables and provide an overview of future directions in risk stratification and SCD prevention.
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Affiliation(s)
- Daniel García Iglesias
- Arrhythmia Unit, Cardiology Department, Hospital Universitario Central de Asturias Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias Oviedo, Spain
| | - José Rubín
- Arrhythmia Unit, Cardiology Department, Hospital Universitario Central de Asturias Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias Oviedo, Spain
| | - Diego Pérez
- Arrhythmia Unit, Cardiology Department, Hospital Universitario Central de Asturias Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias Oviedo, Spain
| | - César Morís
- Arrhythmia Unit, Cardiology Department, Hospital Universitario Central de Asturias Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias Oviedo, Spain
| | - David Calvo
- Arrhythmia Unit, Cardiology Department, Hospital Universitario Central de Asturias Oviedo, Spain.,Instituto de Investigación Sanitaria del Principado de Asturias Oviedo, Spain
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31
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Delise P, Probst V, Allocca G, Sitta N, Sciarra L, Brugada J, Kamakura S, Takagi M, Giustetto C, Calo L. Clinical outcome of patients with the Brugada type 1 electrocardiogram without prophylactic implantable cardioverter defibrillator in primary prevention: a cumulative analysis of seven large prospective studies. Europace 2019; 20:f77-f85. [PMID: 29036426 PMCID: PMC6018881 DOI: 10.1093/europace/eux226] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 06/17/2017] [Indexed: 12/31/2022] Open
Abstract
Aims Patients with the Brugada type 1 ECG (Br type 1) without previous aborted sudden death (aSD) who do not have a prophylactic ICD constitute a very large population whose outcome is little known. The objective of this study was to evaluate the risk of SD or aborted SD (aSD) in these patients. Methods and results We conducted a meta-analysis and cumulative analysis of seven large prospective studies involving 1568 patients who had not received a prophylactic ICD in primary prevention. Patients proved to be heterogeneous. Many were theoretically at low risk, in that they had a drug-induced Br type 1 (48%) and/or were asymptomatic (87%), Others, in contrast, had one or more risk factors. During a mean/median follow-up ranging from 30 to 48 months, 23 patients suffered SD and 1 had aSD. The annual incidence of SD/aSD was 0.5% in the total population, 0.9% in patients with spontaneous Br type 1 and 0.08% in those with drug-induced Br type 1 (P = 0.0001). The paper by Brugada et al. reported an incidence of SD more than six times higher than the other studies, probably as a result of selection bias. On excluding this paper, the annual incidence of SD/aSD in the remaining 1198 patients fell to 0.22% in the total population and to 0.38 and 0.06% in spontaneous and drug-induced Br type 1, respectively. Of the 24 patients with SD/aSD, 96% were males, the mean age was 39 ± 15 years, 92% had spontaneous Br type 1, 61% had familial SD (f-SD), and only 18.2% had a previous syncope; 43% had a positive electrophysiological study. Multiple meta-analysis of individual trials showed that spontaneous Br type 1, f-SD, and previous syncope increased the risk of SD/aSD (RR 2.83, 2.49, and 3.03, respectively). However, each of these three risk factors had a very low positive predictive value (PPV) (1.9-3.3%), while negative predictive values (NPV) were high (98.5-99.7%). The incidence of SD/aSD was only slightly higher in patients with syncope than in asymptomatic patients (2% vs. 1.5%, P = 0.6124). Patients with SD/aSD when compared with the others had a mean of 1.74 vs. 0.95 risk factors (P = 0.026). Conclusion (i) In patients with Br type 1 ECG without an ICD in primary prevention, the risk of SD/aSD is low, particularly in those with drug-induced Br type 1; (ii) spontaneous Br type 1, f-SD, and syncope increase the risk. However, each of these risk factors individually has limited clinical usefulness, owing to their very low PPV; (iii) patients at highest risk are those with more than one risk factor.
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Affiliation(s)
- Pietro Delise
- Ospedale P. Pederzoli, via Monte Baldo 24, Peschiera del Garda (Verona), Italy.,Divisione di Cardiologia, Ospedale di Conegliano, via Brigata Bisagno 4, 31015 Conegliano (Treviso), Italy
| | - Vincent Probst
- Service de cardiologie du CHU de Nantes, Hopital Nord, Bd Jacques Monod 44093, Nantes Cedex, France
| | - Giuseppe Allocca
- Divisione di Cardiologia, Ospedale di Conegliano, via Brigata Bisagno 4, 31015 Conegliano (Treviso), Italy
| | - Nadir Sitta
- Divisione di Cardiologia, Ospedale di Conegliano, via Brigata Bisagno 4, 31015 Conegliano (Treviso), Italy
| | - Luigi Sciarra
- Divion of Cardiology, Casilino Hospital, Roma, Italy
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clinic Pediatric Arrhythmia Unit, Hospital Sant Joan de Deu University of Barcellona, Barcellona, Spain
| | - Shiro Kamakura
- Division of Cardiology, National Cardiovascular Center, Suita, Japan
| | - Masahiko Takagi
- Department of Internal Medicine and Cardiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Carla Giustetto
- Division of Cardiology, Cardinal Massaia Hospital, University of Torino, Italy
| | - Leonardo Calo
- Divion of Cardiology, Casilino Hospital, Roma, Italy
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32
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Tachibana M, Nishii N, Banba K, Fujita S, Ikeda E, Okawa K, Morita H, Ito H. SMART pass will prevent inappropriate operation of S-ICD. J Arrhythm 2019; 35:86-91. [PMID: 30805048 PMCID: PMC6373830 DOI: 10.1002/joa3.12141] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/04/2018] [Accepted: 10/21/2018] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Compared to screening ECG before implantation of a subcutaneous implantable cardioverter-defibrillator (S-ICD), selectable vectors without T-wave oversensing increase after S-ICD implantation. Newer algorithms have recently become available to reduce T-wave oversensing, such as SMART pass (SP). With this function, more selectable vectors are identified after S-ICD implantation. However, this improvement in eligibility utilizing SP has not yet been well validated. We aimed to clarify S-ICD eligibility before and after S-ICD implantation with and without SP. METHODS Participants comprised 34 patients implanted with an S-ICD at Okayama University Hospital and its affiliated hospitals between February 2016 and August 2017. A total of 102 S-ICD vectors were assessed for eligibility before and after S-ICD implantation, at rest and during exercise testing. Vector availability was evaluated in the presence and absence of SP after S-ICD implantation. RESULTS Subcutaneous implantable cardioverter-defibrillator eligibility was significantly better after implantation even without SP than S-ICD screening before S-ICD implantation, both at rest (before 65.7% vs after 95.1%, P < 0.01) and during exercise (before 59.3% vs after 90.6%, P < 0.01). SP improved S-ICD eligibility during exercise (SP on 97.9% vs off 90.6%, P = 0.03). Multivariate analysis showed the prevalence of S-ICD eligibility increased significantly after S-ICD implantation compared to screening before implantation. SP further increased selectable vectors in multivariate analysis. CONCLUSION Available vectors increased significantly after S-ICD implantation compared to preoperative vectors as assessed by S-ICD screening ECG. T-wave oversensing during exercise has been an unresolved issue for S-ICD, but SP will help prevent inappropriate operation with S-ICD.
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Affiliation(s)
- Motomi Tachibana
- Department of CardiologySakakibara Heart Institute of OkayamaOkayamaJapan
| | - Nobuhiro Nishii
- Department of Cardiovascular TherapeuticsOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Kimikazu Banba
- Department of CardiologySakakibara Heart Institute of OkayamaOkayamaJapan
| | - Shinpei Fujita
- Department of CardiologyFukuyama City HospitalFukuyamaJapan
| | - Etsuko Ikeda
- Department of CardiologyTsuyama Central HospitalOkayamaJapan
| | - Keisuke Okawa
- Department of CardiologyKagawa Prefecture Central HospitalKagawaJapan
| | - Hiroshi Morita
- Department of Cardiovascular TherapeuticsOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
| | - Hiroshi Ito
- Department of Cardiovascular MedicineOkayama University Graduate School of Medicine, Dentistry and Pharmaceutical SciencesOkayamaJapan
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Leong KM, Ng FS, Jones S, Chow JJ, Qureshi N, Koa-Wing M, Linton NW, Whinnett ZI, Lefroy DC, Davies DW, Lim PB, Peters NS, Kanagaratnam P, Varnava AM. Prevalence of spontaneous type I ECG pattern, syncope, and other risk markers in sudden cardiac arrest survivors with Brugada syndrome. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:257-264. [DOI: 10.1111/pace.13587] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/17/2018] [Accepted: 11/24/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Kevin M.W. Leong
- National Heart and Lung Institute; Imperial College London; London UK
- Imperial College Healthcare NHS Trust; London UK
| | - Fu Siong Ng
- National Heart and Lung Institute; Imperial College London; London UK
- Imperial College Healthcare NHS Trust; London UK
| | - Sian Jones
- Imperial College Healthcare NHS Trust; London UK
| | - Ji-Jian Chow
- National Heart and Lung Institute; Imperial College London; London UK
- Imperial College Healthcare NHS Trust; London UK
| | | | | | - Nicholas W.F. Linton
- National Heart and Lung Institute; Imperial College London; London UK
- Imperial College Healthcare NHS Trust; London UK
| | - Zachary I. Whinnett
- National Heart and Lung Institute; Imperial College London; London UK
- Imperial College Healthcare NHS Trust; London UK
| | | | | | - Phang Boon Lim
- National Heart and Lung Institute; Imperial College London; London UK
- Imperial College Healthcare NHS Trust; London UK
| | - Nicholas S. Peters
- National Heart and Lung Institute; Imperial College London; London UK
- Imperial College Healthcare NHS Trust; London UK
| | - Prapa Kanagaratnam
- National Heart and Lung Institute; Imperial College London; London UK
- Imperial College Healthcare NHS Trust; London UK
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Calvo M, Le Rolle V, Romero D, Béhar N, Gomis P, Mabo P, Hernández AI. Recursive model identification for the analysis of the autonomic response to exercise testing in Brugada syndrome. Artif Intell Med 2018; 97:98-104. [PMID: 30503015 DOI: 10.1016/j.artmed.2018.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/05/2018] [Accepted: 11/20/2018] [Indexed: 02/05/2023]
Abstract
This paper proposes the integration and analysis of a closed-loop model of the baroreflex and cardiovascular systems, focused on a time-varying estimation of the autonomic modulation of heart rate in Brugada syndrome (BS), during exercise and subsequent recovery. Patient-specific models of 44 BS patients at different levels of risk (symptomatic and asymptomatic) were identified through a recursive evolutionary algorithm. After parameter identification, a close match between experimental and simulated signals (mean error = 0.81%) was observed. The model-based estimation of vagal and sympathetic contributions were consistent with physiological knowledge, enabling to observe the expected autonomic changes induced by exercise testing. In particular, symptomatic patients presented a significantly higher parasympathetic activity during exercise, and an autonomic imbalance was observed in these patients at peak effort and during post-exercise recovery. A higher vagal modulation during exercise, as well as an increasing parasympathetic activity at peak effort and a decreasing vagal contribution during post-exercise recovery could be related with symptoms and, thus, with a worse prognosis in BS. This work proposes the first evaluation of the sympathetic and parasympathetic responses to exercise testing in patients suffering from BS, through the recursive identification of computational models; highlighting important trends of clinical relevance that provide new insights into the underlying autonomic mechanisms regulating the cardiovascular system in BS. The joint analysis of the extracted autonomic parameters and classic electrophysiological markers could improve BS risk stratification.
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Affiliation(s)
- Mireia Calvo
- Univ Rennes, CHU Rennes, Inserm, LTSI UMR 1099, F-35000 Rennes, France
| | - Virginie Le Rolle
- Univ Rennes, CHU Rennes, Inserm, LTSI UMR 1099, F-35000 Rennes, France.
| | - Daniel Romero
- Institute for Bioengineering of Catalonia, E-08930 Barcelona, Spain
| | - Nathalie Béhar
- Univ Rennes, CHU Rennes, Inserm, LTSI UMR 1099, F-35000 Rennes, France
| | - Pedro Gomis
- Universitat Politècnica de Catalunya, E-08028 Barcelona, Spain; CIBER of Bioengineering, Biomaterials and Nanomedicine, E-50018 Zaragoza, Spain
| | - Philippe Mabo
- Univ Rennes, CHU Rennes, Inserm, LTSI UMR 1099, F-35000 Rennes, France
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Steinskog DM, Solberg EE. Sudden cardiac arrest in sports: a video analysis. Br J Sports Med 2018; 53:1293-1298. [DOI: 10.1136/bjsports-2018-099578] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2018] [Indexed: 11/04/2022]
Abstract
ObjectivesInformation about sudden cardiac arrest (SCA) in sports arises from registries, insurance claims and various reports. Analysing video footage of SCA during sports for scientific purposes has scarcely been done. The objective of this study was to examine videotaped SCA in athletes to better understand the mechanisms of SCA.MethodsPublicly available online video databases were searched for videos displaying SCA in athletes.ResultsThirty-five online videos (26 from professional and 9 from amateur sport; 34 male victims) were obtained. Twenty-one events resulted in survival and 14 in sudden cardiac death. Level of physical activity prior to SCA was assessable in 28 videos; 19 events occurred during low-intensity, 6 during moderate-intensity and 3 during high-intensity activity. SCA predominately occurred during low-intensity compared with both moderate-intensity and high-intensity activities (p<0.01). In 26/35 videos, it was possible to observe if resuscitation was provided. Resuscitation was carried out in 20 cases; cardiopulmonary resuscitation (CPR) alone (8 cases), CPR+defibrillation (10), cardiac thump (1) or shock from an implantable cardioverter defibrillator (1). Thirteen of the 20 cases with resuscitation received an intervention within 1 min after collapse. Survival was high when intervention occurred within 1 min (12/13) compared with those who received delayed (3/5) or no intervention (1/6). Associated signs of SCA such as agonal respirations and seizure-like movements were observed in 66% of the cases.ConclusionsSCA during sport most often occurred during low-intensity activity. Prompt intervention within 1 min demonstrated a high survival rate and should be the standard expectation for witnessed SCA in athletes.
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36
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Progression of electrocardiographic abnormalities associated with initial ventricular fibrillation in asymptomatic patients with Brugada syndrome. Heart Rhythm 2018; 15:1468-1474. [DOI: 10.1016/j.hrthm.2018.06.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Indexed: 11/21/2022]
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Abstract
Early repolarization, Brugada syndrome, and pathologic J waves have been described for decades, but only recently experimental and clinical data have allowed reconciliation of Brugada and Early Repolarization under the common definition of J-wave syndromes. The concept was derived from studies showing, in both conditions, the presence of transmural dispersion of repolarization, localized conduction abnormalities, and abnormal transition between QRS and ST segment on electrocardiogram. Although several clinical studies have addressed the clinical presentation and epidemiology of J-wave syndromes, relevant knowledge gaps exist. Incomplete pathophysiologic understanding and uncertain electrocardiographic definitions limit effective risk stratification. Here, we review the current knowledge and recommendations for diagnosis and clinical management of these arrhythmogenic disorders.
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Affiliation(s)
- Silvia G Priori
- Molecular Cardiology, ICS Maugeri, IRCCS, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy.
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Abstract
INTRODUCTION Brugada syndrome (BrS) is an inherited cardiac arrhythmia syndrome characterized by ST-segment elevation in right precordial ECG leads and associated with sudden cardiac death in young adults. The ECG manifestations of BrS are often concealed but can be unmasked by sodium channel blockers and fever. Areas covered: Implantation of a cardioverter defibrillator (ICD) is first-line therapy for BrS patients presenting with prior cardiac arrest or documented VT. A pharmacological approach to therapy is recommended in cases of electrical storm, as an adjunct to ICD and as preventative therapy. The goal of pharmacological therapy is to produce an inward shift to counter the genetically-induced outward shift of ion channel current flowing during the early phases of the ventricular epicardial action potential. This is accomplished by augmentation of ICa using □□adrenergic agents or phosphodiesterase III inhibitors or via inhibition of Ito. Radiofrequency ablation of the right ventricular outward flow tract epicardium is effective in suppressing arrhythmogenesis in BrS patients experiencing frequent appropriate ICD-shocks. Expert commentary: Understanding of the pathophysiology and approach to therapy of BrS has advanced considerably in recent years, but there remains an urgent need for development of cardio-selective and ion-channel-specific Ito blockers for treatment of BrS.
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Affiliation(s)
- Mariana Argenziano
- a Cardiovascular Research , Lankenau Institute for Medical Research , Wynnewood , PA , USA
| | - Charles Antzelevitch
- a Cardiovascular Research , Lankenau Institute for Medical Research , Wynnewood , PA , USA.,b Cardiovascular Research , Lankenau Heart Institute , Wynnewood , PA , USA.,c Department of Medicine and Pharmacology and Experimental Therapeutics , Sidney Kimmel Medical College of Thomas Jefferson University , Philadelphia , PA , USA
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39
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Calvo M, Romero D, Le Rolle V, Béhar N, Gomis P, Mabo P, Hernández AI. Multivariate classification of Brugada syndrome patients based on autonomic response to exercise testing. PLoS One 2018; 13:e0197367. [PMID: 29763454 PMCID: PMC5953462 DOI: 10.1371/journal.pone.0197367] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 05/01/2018] [Indexed: 01/08/2023] Open
Abstract
Ventricular arrhythmias in Brugada syndrome (BS) typically occur at rest and especially during sleep, suggesting that changes in the autonomic modulation may play an important role in arrhythmogenesis. The autonomic response to exercise and subsequent recovery was evaluated on 105 patients diagnosed with BS (twenty-four were symptomatic), by means of a time-frequency heart rate variability (HRV) analysis, so as to propose a novel predictive model capable of distinguishing symptomatic and asymptomatic BS populations. During incremental exercise, symptomatic patients showed higher HFnu values, probably related to an increased parasympathetic modulation, with respect to asymptomatic subjects. In addition, those extracted HRV features best distinguishing between populations were selected using a two-step feature selection approach, so as to build a linear discriminant analysis (LDA) classifier. The final features subset included one third of the total amount of extracted autonomic markers, mostly acquired during incremental exercise and active recovery, thus evidencing the relevance of these test segments in BS patients classification. The derived predictive model showed an improved performance with respect to previous works in the field (AUC = 0.92 ± 0.01; Se = 0.91 ± 0.06; Sp = 0.90 ± 0.05). Therefore, based on these findings, some of the analyzed HRV markers and the proposed model could be useful for risk stratification in Brugada syndrome.
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Affiliation(s)
- Mireia Calvo
- Univ Rennes, CHU Rennes, Inserm, LTSI – UMR 1099, Rennes, France
- Dept. ESAII, CREB, Universitat Politècnica de Catalunya, Barcelona, Spain
| | - Daniel Romero
- Univ Rennes, CHU Rennes, Inserm, LTSI – UMR 1099, Rennes, France
| | - Virginie Le Rolle
- Univ Rennes, CHU Rennes, Inserm, LTSI – UMR 1099, Rennes, France
- * E-mail:
| | - Nathalie Béhar
- Univ Rennes, CHU Rennes, Inserm, LTSI – UMR 1099, Rennes, France
| | - Pedro Gomis
- Dept. ESAII, CREB, Universitat Politècnica de Catalunya, Barcelona, Spain
- CIBER of Bioengineering, Biomaterials and Nanomedicine, Zaragoza, Spain
| | - Philippe Mabo
- Univ Rennes, CHU Rennes, Inserm, LTSI – UMR 1099, Rennes, France
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40
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Asvestas D, Tse G, Baranchuk A, Bazoukis G, Liu T, Saplaouras A, Korantzopoulos P, Goga C, Efremidis M, Sideris A, Letsas KP. High risk electrocardiographic markers in Brugada syndrome. IJC HEART & VASCULATURE 2018; 18:58-64. [PMID: 29876505 PMCID: PMC5988483 DOI: 10.1016/j.ijcha.2018.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/27/2018] [Accepted: 03/01/2018] [Indexed: 12/19/2022]
Abstract
Several clinical, electrocardiographic (ECG) and electrophysiological markers have been proposed to provide optimal risk stratification in patients with Brugada syndrome (BrS). Of the different markers, only a spontaneous type 1 ECG pattern has clearly shown a sufficiently high predictive value. This review article highlights specific ECG markers based on depolarization and/or repolarization that have been associated with an increased risk of arrhythmic events in patients with BrS.
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Affiliation(s)
- Dimitrios Asvestas
- Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece
| | - Gary Tse
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, SAR, PR China
- Li Ka Shing Institute of Health Sciences, 30-32 Ngan Shing St, Chinese University of Hong Kong, Hong Kong, SAR, PR China
| | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston General Hospital, Kingston, Ontario, Canada
| | - George Bazoukis
- Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece
| | - Tong Liu
- Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, PR China
| | - Athanasios Saplaouras
- Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece
| | | | - Christina Goga
- Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece
| | - Michael Efremidis
- Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece
| | - Antonios Sideris
- Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece
| | - Konstantinos P. Letsas
- Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Greece
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Pablo Flórez J, García D, Valverde I, Rubín J, Pérez D, González-Vasserot M, Reguero J, María de la Hera J, Avanzas P, Gómez J, Coto E, Morís C, Calvo D. Role of syncope in predicting adverse outcomes in patients with suspected Brugada syndrome undergoing standardized flecainide testing. Europace 2017; 20:f64-f71. [DOI: 10.1093/europace/eux315] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 09/11/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Juan Pablo Flórez
- Department of Cadiology, Hospital Universitario Central de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
| | - Daniel García
- Department of Cadiology, Hospital Universitario Central de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
| | - Irene Valverde
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Department of Cadiology, Hospital de Cabueñes, C/Los Prados, 395, 33394 Gijón, Asturias, Spain
| | - José Rubín
- Department of Cadiology, Hospital Universitario Central de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
| | - Diego Pérez
- Department of Cadiology, Hospital Universitario Central de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
| | - Mar González-Vasserot
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Department of Cadiology, Hospital de Cabueñes, C/Los Prados, 395, 33394 Gijón, Asturias, Spain
| | - Julián Reguero
- Department of Cadiology, Hospital Universitario Central de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
| | - Jesús María de la Hera
- Department of Cadiology, Hospital Universitario Central de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
| | - Pablo Avanzas
- Department of Cadiology, Hospital Universitario Central de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
| | - Juan Gómez
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Department of Molecular Genetics, Hospital Universitario Central de Asturias, C/Avd. de Roma, s/n, 33006 Oviedo, Spain
| | - Eliecer Coto
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Department of Molecular Genetics, Hospital Universitario Central de Asturias, C/Avd. de Roma, s/n, 33006 Oviedo, Spain
| | - César Morís
- Department of Cadiology, Hospital Universitario Central de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
| | - David Calvo
- Department of Cadiology, Hospital Universitario Central de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, C/Avd de Roma, s/n, 33006 Oviedo, Spain
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42
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Exercise participation and shared decision-making in patients with inherited channelopathies and cardiomyopathies. Heart Rhythm 2017; 15:915-920. [PMID: 29248563 DOI: 10.1016/j.hrthm.2017.12.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Indexed: 01/02/2023]
Abstract
Sports eligibility and disqualification of patients with cardiac diseases are important considerations for adult and pediatric cardiologists. The 2005 guidelines that addressed this issue have recently been revised and updated, and the new guidelines advocate for a shared decision-making approach in which the well-informed athlete and family participate in the discussion. In this review, we focus on the benefits of sports participation and review the revised guidelines related to sports participation in patients with channelopathies and cardiomyopathies.
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43
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Leong KMW, Ng FS, Roney C, Cantwell C, Shun-Shin MJ, Linton NWF, Whinnett ZI, Lefroy DC, Davies DW, Harding SE, Lim PB, Francis D, Peters NS, Varnava AM, Kanagaratnam P. Repolarization abnormalities unmasked with exercise in sudden cardiac death survivors with structurally normal hearts. J Cardiovasc Electrophysiol 2017; 29:115-126. [PMID: 29091329 DOI: 10.1111/jce.13375] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 09/13/2017] [Accepted: 09/25/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Models of cardiac arrhythmogenesis predict that nonuniformity in repolarization and/or depolarization promotes ventricular fibrillation and is modulated by autonomic tone, but this is difficult to evaluate in patients. We hypothesize that such spatial heterogeneities would be detected by noninvasive ECG imaging (ECGi) in sudden cardiac death (SCD) survivors with structurally normal hearts under physiological stress. METHODS ECGi was applied to 11 SCD survivors, 10 low-risk Brugada syndrome patients (BrS), and 10 controls undergoing exercise treadmill testing. ECGi provides whole heart activation maps and >1,200 unipolar electrograms over the ventricular surface from which global dispersion of activation recovery interval (ARI) and regional delay in conduction were determined. These were used as surrogates for spatial heterogeneities in repolarization and depolarization. Surface ECG markers of dispersion (QT and Tpeak-end intervals) were also calculated for all patients for comparison. RESULTS Following exertion, the SCD group demonstrated the largest increase in ARI dispersion compared to BrS and control groups (13 ± 8 ms vs. 4 ± 7 ms vs. 4 ± 5 ms; P = 0.009), with baseline dispersion being similar in all groups. In comparison, surface ECG markers of dispersion of repolarization were unable to discriminate between the groups at baseline or following exertion. Spatial heterogeneities in conduction were also present following exercise but were not significantly different between SCD survivors and the other groups. CONCLUSION Increased dispersion of repolarization is apparent during physiological stress in SCD survivors and is detectable with ECGi but not with standard ECG parameters. The electrophysiological substrate revealed by ECGi could be the basis of alternative risk-stratification techniques.
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Affiliation(s)
- Kevin M W Leong
- National Heart & Lung Institute, Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Fu Siong Ng
- National Heart & Lung Institute, Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Caroline Roney
- National Heart & Lung Institute, Imperial College London, London, UK
| | | | | | | | - Zachary I Whinnett
- National Heart & Lung Institute, Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | | | - D Wyn Davies
- Imperial College Healthcare NHS Trust, London, UK
| | - Sian E Harding
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Phang Boon Lim
- National Heart & Lung Institute, Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Darrel Francis
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Nicholas S Peters
- National Heart & Lung Institute, Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | | | - Prapa Kanagaratnam
- National Heart & Lung Institute, Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
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44
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Tomé G, Freitas J. Induced Brugada syndrome: Possible sources of arrhythmogenesis. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.repce.2017.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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45
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Induced Brugada syndrome: Possible sources of arrhythmogenesis. Rev Port Cardiol 2017; 36:945-956. [PMID: 29233646 DOI: 10.1016/j.repc.2017.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 06/16/2017] [Accepted: 06/20/2017] [Indexed: 11/24/2022] Open
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46
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Letsas KP, Asvestas D, Baranchuk A, Liu T, Georgopoulos S, Efremidis M, Korantzopoulos P, Bazoukis G, Tse G, Sideris A, Takagi M, Ehrlich JR. Prognosis, risk stratification, and management of asymptomatic individuals with Brugada syndrome: A systematic review. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1332-1345. [PMID: 28994463 DOI: 10.1111/pace.13214] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/30/2017] [Accepted: 09/10/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Konstantinos P. Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology; Evangelismos General Hospital of Athens; Athens Greece
| | - Dimitrios Asvestas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology; Evangelismos General Hospital of Athens; Athens Greece
| | - Adrian Baranchuk
- Division of Cardiology, Queen's University; Kingston General Hospital; Kingston Ontario Canada
| | - Tong Liu
- Department of Cardiology, Tianjin Institute of Cardiology; Second Hospital of Tianjin Medical University; Tianjin P.R. China
| | - Stamatis Georgopoulos
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology; Evangelismos General Hospital of Athens; Athens Greece
| | - Michael Efremidis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology; Evangelismos General Hospital of Athens; Athens Greece
| | | | - George Bazoukis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology; Evangelismos General Hospital of Athens; Athens Greece
| | - Gary Tse
- Department of Medicine and Therapeutics; Chinese University of Hong Kong; Hong Kong SAR P.R. China
- Li Ka Shing Institute of Health Sciences; Chinese University of Hong Kong; Hong Kong SAR P.R. China
| | - Antonios Sideris
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology; Evangelismos General Hospital of Athens; Athens Greece
| | - Masahiko Takagi
- Department of Cardiovascular Medicine; Osaka City University Graduate School of Medicine; Osaka Japan
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47
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Behar N, Petit B, Probst V, Sacher F, Kervio G, Mansourati J, Bru P, Hernandez A, Mabo P. Heart rate variability and repolarization characteristics in symptomatic and asymptomatic Brugada syndrome. Europace 2017; 19:1730-1736. [PMID: 27738060 DOI: 10.1093/europace/euw224] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 06/27/2016] [Indexed: 11/13/2022] Open
Abstract
Aim Modulation of ST-segment elevation (STE) and tachyarrhythmic events by the autonomic nervous system (ANS) has been reported in patients with Brugada syndrome (BS). This study examined and compared the autonomic characteristics and STE in symptomatic vs. asymptomatic patients with BS. Methods and result We studied 40 symptomatic and 78 asymptomatic patients (mean age = 46.1 ± 13.7 years; 88 men) who underwent 24 h, 12-lead electrocardiograms, and exercise and a head-up tilt tests. Heart rate variability was examined and STE was measured at 5 points between 100 and 140 ms after the onset of 1 min averaged QRS complexes, and the type 1 Brugada pattern was automatically identified. 'Type 1 Brugada burden' was the percentage of averaged type 1 complexes. All measurements were made over 24 h, and during day and night times. During daytime, the variation coefficients of standard deviation of normal-to-normal intervals were 39.0 ± 12.3 vs. 34.1 ± 14.5 ms (P< 0.05) and high frequency normalized units were 39.9 ± 16.9 vs. 33.9 ± 16.2% (P< 0.05) in symptomatic vs. asymptomatic patients, respectively. ST-segment elevation was similar in symptomatic and asymptomatic patients at all time points. The type 1 Brugada burden in V2 was 38.7 ± 33.6% in the symptomatic vs. 24.3 ± 35.2% in the asymptomatic sample, a statistically non-significant difference. Conclusion This analysis of ANS did not identify sensitive predictors of arrhythmic events in patients with BS. We observed, however, greater fluctuations in sinus node response to ANS in symptomatic patients. The type 1 Brugada electrocardiographic pattern was not as reliable a predictor of arrhythmic risk as previously reported.
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Affiliation(s)
- Nathalie Behar
- Cardiology and Vascular Disease Division, Rennes University Health Centre, 35033 Rennes cedex, France
| | - Bertrand Petit
- Cardiology division, GH sud Réunion, 97410 Saint Pierre La Réunion, France
| | - Vincent Probst
- Cardiology division, Nantes University Health Centre, 44093 Nantes cedex, France
| | - Frederic Sacher
- LIRYC Institute, INSERM 1045, Bordeaux University Hospital, Bordeaux, France
| | - Gaelle Kervio
- Inserm 1414 Clinical Investigation Center, Innovative Technology, Rennes F-35000, France
| | - Jacques Mansourati
- Department of Cardiology, Brest University Health Centre, 29609 Brest, France
| | - Paul Bru
- Cardiology division, La Rochelle Health Centre, 17019 La Rochelle, France
| | | | - Philippe Mabo
- Cardiology and Vascular Disease Division, Rennes University Health Centre, 35033 Rennes cedex, France
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48
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Abstract
Brugada syndrome (BrS) is one of the commonest inherited primary arrhythmia syndromes typically presenting with arrhythmic syncope or sudden cardiac death (SCD) due to polymorphic ventricular tachycardia and ventricular fibrillation precipitated by vagotonia or fever in apparently healthy adults, less frequently in children. The prevalence of the syndrome (0.01%-0.3%) varies among regions and ethnicities, being the highest in Southeast Asia. BrS is diagnosed by the "coved type" ST-segment elevation≥2mm followed by a negative T-wave in ≥1 of the right precordial leads V1-V2. The typical electrocardiogram in BrS is often concealed by fluctuations between normal, non-diagnostic and diagnostic ST-segment pattern in the same patient, thus hindering the diagnosis. Presently, the majority of BrS patients is incidentally diagnosed, and may remain asymptomatic for their lifetime. However, BrS is responsible for 4-12% of all SCDs and for ~20% of SCDs in patients with structurally normal hearts. Arrhythmic risk is the highest in SCD survivors and in patients with spontaneous BrS electrocardiogram and arrhythmic syncope, but risk stratification for SCD in asymptomatic subjects has not yet been fully defined. Recent achievements have expanded our understanding of the genetics and electrophysiological mechanisms underlying BrS, while radiofrequency catheter ablation may be an effective new approach to treat ventricular tachyarrhythmias in BrS patients with arrhythmic storms. The present review summarizes our contemporary understanding and recent advances in the inheritance, pathophysiology, clinical assessment and treatment of BrS patients.
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Affiliation(s)
- Marija M Polovina
- School of Medicine, Belgrade University, Belgrade, Serbia; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Bojan Banko
- Centre for Radiology and MRI, Clinical Centre of Serbia, Belgrade, Serbia
| | - Gregory Y H Lip
- School of Medicine, Belgrade University, Belgrade, Serbia; University of Birmingham, Institute of Cardiovascular Science, City Hospital, Birmingham, United Kingdom
| | - Tatjana S Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia; Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia.
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Therasse D, Sacher F, Petit B, Babuty D, Mabo P, Martins R, Jesel L, Maury P, Pasquie JL, Mansourati J, Dupuis JM, Kyndt F, Thollet A, Guyomarch B, Barc J, Schott JJ, Le Marec H, Redon R, Probst V, Gourraud JB. Sodium-channel blocker challenge in the familial screening of Brugada syndrome: Safety and predictors of positivity. Heart Rhythm 2017; 14:1442-1448. [DOI: 10.1016/j.hrthm.2017.06.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Indexed: 10/19/2022]
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50
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Tachibana M, Nishii N, Morita H, Nakagawa K, Watanabe A, Nakamura K, Ito H. Exercise stress test reveals ineligibility for subcutaneous implantable cardioverter defibrillator in patients with Brugada syndrome. J Cardiovasc Electrophysiol 2017; 28:1454-1459. [DOI: 10.1111/jce.13315] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/30/2017] [Accepted: 08/07/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Motomi Tachibana
- Department of Cardiology; Sakakibara Heart Institute of Okayama; Okayama Japan
| | - Nobuhiro Nishii
- Department of Cardiovascular Therapeutics; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Hiroshi Morita
- Department of Cardiovascular Therapeutics; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
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