Clinical and electrophysiological profile of Brugada syndrome in the Tunisian population

Sudden death in young South European population: a cross-sectional study of postmortem cases

To describe the annual incidence and the leading causes of sudden non-cardiac and cardiac death (SCD) in children and young adult Portuguese population. We retrospectively reviewed autopsy of sudden unexpected deaths reports from the Portuguese National Institute of Legal Medicine and Forensic Sciences' database, between 2012 and 2016, for the central region of Portugal, Azores and Madeira (ages 1-40: 26% of the total population). During a 5-year period, 159 SD were identified, corresponding to an annual incidence of 2,4 (95%confidence interval, 1,5-3,6) per 100.000 people-years. Victims had a mean age of 32 ± 7 years-old, and 72,3% were male. There were 70,4% cardiac, 16,4% respiratory and 7,5% neurologic causes of SD. The most frequent cardiac anatomopathological diagnosis was atherosclerotic coronary artery disease (CAD) (33,0%). There were 15,2% victims with left ventricular hypertrophy, with a diagnosis of hypertrophic cardiomyopathy only possible in 2,7%. The prevalence of cardiac pathological findings of uncertain significance was 30,4%. In conclusion, the annual incidence of SD was low. Atherosclerotic CAD was diagnosed in 33,0% victims, suggesting the need to intensify primary prevention measures in the young. The high prevalence of pathological findings of uncertain significance emphasizes the importance of molecular autopsy and screening of first-degree relatives.

Does the Age of Sudden Cardiac Death in Family Members Matter in Brugada Syndrome?

Background Brugada syndrome is an inherited cardiac channelopathy associated with major arrhythmic events (MAEs). The presence of a positive family history of sudden cardiac death (SCD) as a risk predictor of MAE remains controversial. We aimed to examine the association between family history of SCD and MAEs stratified by age of SCD with a systematic review and meta-analysis. Methods and Results We searched the databases of MEDLINE and EMBASE from January 1992 to January 2020. Data from each study were combined using the random-effects model. Fitted metaregression was performed to evaluate the association between the age of SCD in families and the risk of MAE. Twenty-two studies from 2004 to 2019 were included in this meta-analysis involving 3386 patients with Brugada syndrome. The overall family history of SCD was not associated with increased risk of MAE in Brugada syndrome (pooled odds ratio [OR], 1.11; 95% CI, 0.82-1.51; P=0.489, I²=45.0%). However, a history of SCD in family members of age younger than 40 years of age did increase the risk of MAE by ≈2-fold (pooled OR, 2.03; 95% CI, 1.11-3.73; P=0.022, I²=0.0%). When stratified by the age of cut point at 50, 45, 40, and 35 years old, a history of SCD in younger family member was significantly associated with a higher risk of MAE (pooled OR, 0.49, 1.30, 1.51, and 2.97, respectively; P=0.046). Conclusions A history of SCD among family members of age younger than 40 years was associated with a higher risk of MAE.

Cardiac Arrhythmias in Africa: Epidemiology, Management Challenges, and Perspectives

Africa is experiencing an increasing burden of cardiac arrhythmias. Unfortunately, the expanding need for appropriate care remains largely unmet because of inadequate funding, shortage of essential medical expertise, and the high cost of diagnostic equipment and treatment modalities. Thus, patients receive suboptimal care. A total of 5 of 34 countries (15%) in Sub-Saharan Africa (SSA) lack a single trained cardiologist to provide basic cardiac care. One-third of the SSA countries do not have a single pacemaker center, and more than one-half do not have a coronary catheterization laboratory. Only South Africa and several North African countries provide complete services for cardiac arrhythmias, leaving more than hundreds of millions of people in SSA without access to arrhythmia care considered standard in other parts of the world. Key strategies to improve arrhythmia care in Africa include greater government health care funding, increased emphasis on personnel training through fellowship programs, and greater focus on preventive care.

Epidemiology of sudden cardiac death in Cameroon: the first population-based cohort survey in sub-Saharan Africa

Background

Incidence estimates of sudden cardiac death (SCD) in sub-Saharan Africa (SSA) are unknown.

Method

Over 12 months, the household administrative office and health community committee within neighbourhoods in two health areas of Douala, Cameroon, registered all deaths among 86 188 inhabitants aged >18 years. As part of an extended multi-source surveillance system, the Emergency Medical Service (EMS), local medical examiners and district hospital mortuaries were also surveyed. Whereas two physicians investigated every natural death, two cardiologists reviewed all unexpected natural deaths.

Results

There were 288 all-cause deaths and 27 (9.4%) were SCD. The crude incidence rate was 31.3 [95% confidence interval (CI): 20.3–40.6]/100 000 person-years. The age-standardized rate by the African standard population was 33.6 (95% CI: 22.4–44.9)/100 000 person-years. Death occurred at night in 37% of cases, including 11% of patients who died while asleep. Out-of-hospital sudden cardiac arrest occurred in 63% of cases, 55.5% of which occurred at home. Of the 88.9% cases of witnessed cardiac arrest, 63% occurred in the presence of a family member and cardiopulmonary resuscitation was attempted only in 3.7%.

Conclusion

The burden of SCD in this African population is heavy with distinct characteristics, whereas awareness of SCD and prompt resuscitation efforts appear suboptimal. Larger epidemiological studies are required in SSA in order to implement preventive measures, especially in women and young people.

Brugada syndrome revealed by intestinal shigellosis in a patient from Benin at the University Hospital of Saint-Etienne

This paper is about a Brugada syndrome (BS) of accidental discovery in a patient from Benin during an intestinal shigellosis episode in the infectiology department of university hospital of Saint-Etienne, France. Authors establish a link between these two diseases. After a literature's review, they underline that BS is under-diagnosed in Africa. Furthermore, they highlight socio-cultural characteristics of sudden deaths in West Africa including BS.

Risk factors for cardiac events in patients with Brugada syndrome: A PRISMA-compliant meta-analysis and systematic review

INTRODUCTION

Inconsistent results have been reported about the risk stratification of patients with Brugada syndrome. We have summarized the evidence regarding the strength of association between 6 risk factors (family history of sudden cardiac death [SCD] or syncope, inducible ventricular arrhythmias on electrophysiology study [EPS], spontaneous type 1 Brugada electrocardiogram [ECG], male sex, family history of SCD, and sodium voltage-gated channel alpha subunit 5 [SCN5A] gene mutation) and subsequent cardiac events in Brugada syndrome patients.

METHODS

Pubmed, Ovid, Embase, and the Cochrane Library were searched for studies published between January 1992 and March 2016. Only prospective studies (27 studies, 4494 patients) that reported estimates with 95% confidence intervals (CIs) of cardiac events for the 6 risk factors were included.

RESULTS

Family history of SCD or syncope (risk ratio [RR] 4.97, 95% CI 3.96-6.23, P < 0.001), inducible ventricular arrhythmia on EPS (RR 3.56, 95% CI 1.30-9.74, P = 0.01), and spontaneous type 1 Brugada ECG (RR 4.07, 95% CI 2.23-7.41, P < 0.001) were associated with an increased risk of future cardiac events. Spontaneous type 1 Brugada ECG was associated with an elevated risk of future cardiac events in patients without a family history of SCD.

CONCLUSIONS

Inducible ventricular arrhythmias on EPS, spontaneous type 1 Brugada ECG, and family history of SCD or syncope indicate a high risk of future cardiac events in patients with Brugada syndrome. Spontaneous type 1 Brugada ECG significantly increased the risk of future cardiac events in patients without family history of SCD.

Programmed Ventricular Stimulation for Risk Stratification in the Brugada Syndrome: A Pooled Analysis

BACKGROUND

The role of programmed ventricular stimulation in identifying patients with Brugada syndrome at the highest risk for sudden death is uncertain.

METHODS AND RESULTS

We performed a systematic review and pooled analysis of prospective, observational studies of patients with Brugada syndrome without a history of sudden cardiac arrest who underwent programmed ventricular stimulation. We estimated incidence rates and relative hazards of cardiac arrest or implantable cardioverter-defibrillator shock. We analyzed individual-level data from 8 studies comprising 1312 patients who experienced 65 cardiac events (median follow-up, 38.3 months). A total of 527 patients were induced into arrhythmias with up to triple extrastimuli. Induction was associated with cardiac events during follow-up (hazard ratio, 2.66; 95% confidence interval [CI], 1.44-4.92, P<0.001), with the greatest risk observed among those induced with single or double extrastimuli. Annual event rates varied substantially by syncope history, presence of spontaneous type 1 ECG pattern, and arrhythmia induction. The lowest risk occurred in individuals without syncope and with drug-induced type 1 patterns (0.23%, 95% CI, 0.05-0.68 for no induced arrhythmia with up to double extrastimuli; 0.45%, 95% CI, 0.01-2.49 for induced arrhythmia), and the highest risk occurred in individuals with syncope and spontaneous type 1 patterns (2.55%, 95% CI, 1.58-3.89 for no induced arrhythmia; 5.60%, 95% CI, 2.98-9.58 for induced arrhythmia).

CONCLUSIONS

In patients with Brugada syndrome, arrhythmias induced with programmed ventricular stimulation are associated with future ventricular arrhythmia risk. Induction with fewer extrastimuli is associated with higher risk. However, clinical risk factors are important determinants of arrhythmia risk, and lack of induction does not necessarily portend low ventricular arrhythmia risk, particularly in patients with high-risk clinical features.

Epidemiology of sudden cardiac death in Cameroon: rationale and design of the Douala-SUD survey

BACKGROUND

The burden of sudden unexplained death in sub-Saharan Africa is unknown.

AIM

The aim of this study is to establish the epidemiology of sudden cardiac death in Cameroon.

METHODS

The Douala sudden unexplained death (Douala-SUD) study is a prospective, multiple-source, community-based surveillance of all cases of unexpected death (< 24 hours from onset of symptoms) occurring in victims aged>15 years. After approval from institutional boards, all deaths occurring in residents of four areas of Douala city will be checked for circumstances of death and past medical history. Subjects who die naturally will be further investigated. Unexpected death victims will be checked for detailed demographic, clinical, electrocardiographic, echocardiographic and biological records. Autopsy background and genetic analysis (postmortem or in first relatives if the young victim is aged<40 years) will be performed as far as possible. Finally, the use of cardiopulmonary resuscitation efforts during the timeframe of sudden cardiac arrest will also be evaluated.

CONCLUSION

The Douala-SUD study will provide comprehensive, contemporary data on the epidemiology of sudden unexplained and cardiac death in sub-Saharan Africa and will help in the development of strategies to prevent and manage cardiac arrest in Cameroon as well as in other sub-Saharan countries.

Rationale and design of the Pan-African Sudden Cardiac Death survey: the Pan-African SCD study

BACKGROUND

The estimated rate of sudden cardiac death (SCD) in Western countries ranges from 300,000 to 400,000 annually, which represents 0.36 to 1.28 per 1 000 inhabitants in Europe and the United States. The burden of SCD in Africa is unknown. Our aim is to assess the epidemiology of SCD in Africa.

METHODS

The Pan-Africa SCD study is a prospective, multicentre, community-based registry monitoring all cases of cardiac arrest occurring in victims over 15 years old. We will use the definition of SCD as 'witnessed natural death occurring within one hour of the onset of symptoms' or 'unwitnessed natural death within 24 hours of the onset of symptoms'. After approval from institutional boards, we will record demographic, clinical, electrocardiographic and biological variables of SCD victims (including survivors of cardiac arrest) in several African cities. All deaths occurring in residents of districts of interest will be checked for past medical history, circumstances of death, and autopsy report (if possible). We will also analyse the employment of resuscitation attempts during the time frame of sudden cardiac arrest (SCA) in various patient populations throughout African countries.

CONCLUSION

This study will provide comprehensive, contemporary data on the epidemiology of SCD in Africa and will help in the development of strategies to prevent and manage cardiac arrest in this region of the world.

Sudden cardiac death in low- and middle-income countries

Cardiovascular disease, and the incidence of sudden cardiac death (SCD), will increase significantly in low- and middle-income countries (LMIC). Thus, SCD threatens to become a global public health problem. We present a summary of the current research that has investigated the epidemiology of SCD in LMIC. Few studies of SCD in LMIC exist, and they are of variable methodological quality. Risk factors for SCD are described, taking into account recent global burden of disease and risk factor statistics. We describe 1 proposal for a community-based, prospective, multiple-source methodology for SCD monitoring and surveillance that can be implemented in LMIC. Further research into the epidemiology of SCD in LMIC, using standardized methodology, would allow investigators and policy makers to determine the regions, communities, and individuals most at need for SCD prevention. Focusing on SCD and its prevention in LMIC should be a priority for the global health community.