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Bazoukis G, Letsas KP, Liu T, Tse G, Alsheikh-Ali A. Association of Late Potentials With Fatal Arrhythmic Events in Patients With Brugada Syndrome-A Meta-analysis. Cardiol Rev 2024; 32:334-337. [PMID: 37811999 DOI: 10.1097/crd.0000000000000511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Risk stratification of patients with Brugada syndrome (BrS) remains challenging. Signal-averaged electrocardiogram (SAECG) is a noninvasive tool that can be used to identify the electrophysiologic substrate potentially underlying fatal ventricular arrhythmias. The aim of this meta-analysis is to summarize the existing evidence about the role of late potentials (LP) as a predictor for arrhythmic events in patients with BrS. A systematic search in the MedLine database through to June 2022 without any limitations was performed. Ten studies were included in the quantitative synthesis (1431 patients with BrS, mean age 47.4 years, males 86%). Of these, 1220 patients underwent SAECG evaluation (53.2% had positive LP, and 20.6% had a fatal arrhythmic event). There was a nonsignificant association between positive LPs and fatal arrhythmic events [RR: 2.06 (0.98-4.36), P = 0.06, I 2 = 82%]. By including only studies with patients without a history of fatal arrhythmia, the association between LP with arrhythmic events remained nonsignificant [RR: 1.29 (0.67-2.48), P = 0.44, I 2 = 54%]. In conclusion, there is a possible association between LP and fatal arrhythmic events in patients with BrS, but the literature remains inconclusive. Large cohort studies using a multiparametric approach for risk stratification purposes are needed to improve the risk stratification of BrS and to optimize the selection of BrS patients that should be referred for implantable cardioverter-defibrillator.
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Affiliation(s)
- George Bazoukis
- From the Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | - Konstantinos P Letsas
- Arrhythmia Unit, Laboratory of Cardiac Pacing and Electrophysiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Gary Tse
- Kent and Medway Medical School, Canterbury, Kent, United Kingdom
- Cardiac Electrophysiology Unit, Cardiovascular Analytics Group, China-United Kingdom Collaboration, Hong Kong, China
| | - Alawi Alsheikh-Ali
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
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Nakamura T, Aiba T, Shimizu W, Furukawa T, Sasano T. Prediction of the Presence of Ventricular Fibrillation From a Brugada Electrocardiogram Using Artificial Intelligence. Circ J 2023; 87:1007-1014. [PMID: 36372400 DOI: 10.1253/circj.cj-22-0496] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
BACKGROUND Brugada syndrome is a potential cause of sudden cardiac death (SCD) and is characterized by a distinct ECG, but not all patients with A Brugada ECG develop SCD. In this study we sought to examine if an artificial intelligence (AI) model can predict a previous or future ventricular fibrillation (VF) episode from a Brugada ECG. METHODS AND RESULTS We developed an AI-enabled algorithm using a convolutional neural network. From 157 patients with suspected Brugada syndrome, 2,053 ECGs were obtained, and the dataset was divided into 5 datasets for cross-validation. In the ECG-based evaluation, the precision, recall, and F1score were 0.79±0.09, 0.73±0.09, and 0.75±0.09, respectively. The average area under the receiver-operating characteristic curve (AUROC) was 0.81±0.09. On per-patient evaluation, the AUROC was 0.80±0.07. This model predicted the presence of VF with a precision of 0.93±0.02, recall of 0.77±0.14, and F1score of 0.81±0.11. The negative predictive value was 0.94±0.11 while its positive predictive value was 0.44±0.29. CONCLUSIONS This proof-of-concept study showed that an AI-enabled algorithm can predict the presence of VF with a substantial performance. It implies that the AI model may detect a subtle ECG change that is undetectable by humans.
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Affiliation(s)
- Tomofumi Nakamura
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Tetsushi Furukawa
- Department of Bio-informational Pharmacology, Medical Research Institute, Tokyo Medical and Dental University
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
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Rattanawong P, Kewcharoen J, Yinadsawaphan T, Fatunde OA, Kanitsoraphan C, Vutthikraivit W, Prasitlumkum N, Chung EH, Shen W. Type of syncope and outcome in Brugada syndrome: A systematic review and meta-analysis. J Arrhythm 2023; 39:111-120. [PMID: 37021016 PMCID: PMC10068940 DOI: 10.1002/joa3.12822] [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: 10/10/2022] [Revised: 12/24/2022] [Accepted: 01/12/2023] [Indexed: 02/04/2023] Open
Abstract
Introduction Brugada syndrome is an inherited arrhythmic disease associated with major arrhythmic events (MAE). The importance of primary prevention of sudden cardiac death (SCD) in Brugada syndrome is well recognized; however, ventricular arrhythmia risk stratification remains challenging and controversial. We aimed to assess the association of type of syncope with MAE via systematic review and meta-analysis. Methods We comprehensively searched the databases of MEDLINE and EMBASE from inception to December 2021. Included studies were cohort (prospective or retrospective) studies that reported the types of syncope (cardiac, unexplained, vasovagal, and undifferentiated) and MAE. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate the odds ratio (OR) and 95% confidence intervals (CIs). Results Seventeen studies from 2005 to 2019 were included in this meta-analysis involving 4355 Brugada syndrome patients. Overall, syncope was significantly associated with an increased risk of MAE in Brugada syndrome (OR = 3.90, 95% CI: 2.22-6.85, p < .001, I 2 = 76.0%). By syncope type, cardiac (OR = 4.48, 95% CI: 2.87-7.01, p < .001, I 2 = 0.0%) and unexplained (OR = 4.71, 95% CI: 1.34-16.57, p = .016, I 2 = 37.3%) syncope was significantly associated with increased risk of MAE in Brugada syndrome. Vasovagal (OR = 2.90, 95% CI: 0.09-98.45, p = .554, I 2 = 70.9%) and undifferentiated syncope (OR = 2.01, 95% CI: 1.00-4.03, p = .050, I 2 = 64.6%, respectively) were not. Conclusion Our study demonstrated that cardiac and unexplained syncope was associated with MAE risk in Brugada syndrome populations but not in vasovagal syncope and undifferentiated syncope. Unexplained syncope is associated with a similar increased risk of MAE compared to cardiac syncope.
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Affiliation(s)
- Pattara Rattanawong
- Department of Cardiovascular MedicineMayo ClinicPhoenixArizonaUSA
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Jakrin Kewcharoen
- Division of Cardiology, Cardiac Arrhythmia ServiceLoma Linda University HealthLoma LindaCaliforniaUSA
| | - Thanaboon Yinadsawaphan
- Department of Cardiovascular MedicineMayo ClinicPhoenixArizonaUSA
- Department of CardiologyCentral Chest Institute of ThailandNonthaburiThailand
| | | | | | - Wasawat Vutthikraivit
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of IowaIowa CityIowaUSA
| | - Narut Prasitlumkum
- Department of CardiologyUniversity of California RiversideRiversideCaliforniaUSA
| | - Eugene H. Chung
- Department of Internal Medicine, Michigan MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Win‐Kuang Shen
- Department of Cardiovascular MedicineMayo ClinicPhoenixArizonaUSA
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Sharif ZI, Lubitz SA. Ventricular arrhythmia management in patients with genetic cardiomyopathies. Heart Rhythm O2 2021; 2:819-831. [PMID: 34988533 PMCID: PMC8710624 DOI: 10.1016/j.hroo.2021.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Genetic cardiomyopathies are associated with increased risk for cardiac arrhythmias and sudden cardiac death. The management of ventricular arrhythmias (VAs) in patients with these conditions can be nuanced due to particular disease-based considerations, yet data specifically addressing management in these patients are limited. Here we describe the current evidence-based approach to the management of ventricular rhythm disorders in patients with genetic forms of cardiomyopathy, namely, hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, left ventricular noncompaction, and Brugada syndrome, including recommendations from consensus guideline statements when available.
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Affiliation(s)
- Zain I. Sharif
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven A. Lubitz
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
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5
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Chow JJ, Leong KM, Yazdani M, Huzaien HW, Jones S, Shun-Shin MJ, Koa-Wing M, Lefroy DC, Lim PB, Linton NW, Ng FS, Qureshi NA, Whinnett ZI, Peters NS, O'Callaghan P, Yousef Z, Kanagaratnam P, Varnava AM. A Multicenter External Validation of a Score Model to Predict Risk of Events in Patients With Brugada Syndrome. Am J Cardiol 2021; 160:53-59. [PMID: 34610873 DOI: 10.1016/j.amjcard.2021.08.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/14/2021] [Accepted: 08/17/2021] [Indexed: 11/26/2022]
Abstract
A multivariate risk score model was proposed by Sieira et al in 2017 for sudden death in Brugada syndrome; their validation in 150 patients was highly encouraging, with a C-index of 0.81; however, this score is yet to be validated by an independent group. A total of 192 records of patients with Brugada syndrome were collected from 2 centers in the United Kingdom and retrospectively scored according to a score model by Sieira et al. Data were compiled summatively over follow-up to mimic regular risk re-evaluation as per current guidelines. Sudden cardiac death survivor data were considered perievent to ascertain the utility of the score before cardiac arrest. Scores were compared with actual outcomes. Sensitivity in our cohort was 22.7%, specificity was 57.6%, and C-index was 0.58. In conclusion, up to 75% of cardiac arrest survivors in this cohort would not have been offered a defibrillator if evaluated before their event. This casts doubt on the utility of the score model for primary prevention of sudden death. Inherent issues with modern risk scoring strategies decrease the likelihood of success even in robustly designed tools such as the Sieira score model.
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Rattanawong P, Kewcharoen J, Kanitsoraphan C, Barry T, Shanbhag A, Ko Ko NL, Vutthikraivit W, Home M, Agasthi P, Ashraf H, Shimizu W, Shen WK. Does the Age of Sudden Cardiac Death in Family Members Matter in Brugada Syndrome? J Am Heart Assoc 2021; 10:e019788. [PMID: 34013737 PMCID: PMC8483509 DOI: 10.1161/jaha.120.019788] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Pattara Rattanawong
- Department of Cardiovascular Medicine Mayo Clinic Phoenix AZ.,Faculty of Medicine Ramathibodi Hospital Mahidol University Bangkok Thailand
| | - Jakrin Kewcharoen
- University of Hawaii Internal Medicine Residency Program Honolulu HI
| | | | - Timothy Barry
- Department of Cardiovascular Medicine Mayo Clinic Phoenix AZ
| | - Anusha Shanbhag
- Department of Cardiovascular Medicine Mayo Clinic Phoenix AZ
| | - Nway L Ko Ko
- Department of Cardiovascular Medicine Mayo Clinic Phoenix AZ
| | - Wasawat Vutthikraivit
- Division of Cardiovascular Medicine Department of Internal Medicine University of Iowa IA
| | | | | | - Hasan Ashraf
- Department of Cardiovascular Medicine Mayo Clinic Phoenix AZ
| | - Wataru Shimizu
- Department of Cardiovascular Medicine Graduate School of Medicine Nippon Medical School Tokyo Japan
| | - Win-Kuang Shen
- Department of Cardiovascular Medicine Mayo Clinic Phoenix AZ
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Lopez-Blazquez M, Field E, Tollit J, Walsh H, Addis A, French N, Starling L, Kaski JP. Clinical significance of inferolateral early repolarisation and late potentials in children with Brugada Syndrome. J Electrocardiol 2021; 66:79-83. [PMID: 33831794 DOI: 10.1016/j.jelectrocard.2021.03.011] [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: 01/18/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The clinical utility of inferolateral early repolarisation (ER) and late potentials (LP) in children with Brugada Syndrome (BrS) has not been previously evaluated. The aim of this study was to determine the prevalence of electrocardiographic (ECG) abnormalities in children with BrS, and to investigate their relationship with clinical outcomes. METHODS 43 patients with BrS and 47 controls aged ≤18 undergoing systematic clinical and ECG evaluation, including signal-averaged ECG (SAECG) and pharmacological provocation testing, between 2003 and 2019 were included. RESULTS Four patients with BrS (9%) presented with a spontaneous type 1 Brugada pattern; the remaining 39 (91%) were diagnosed following ajmaline provocation testing. Twelve BrS patients (28%) had late potentials (LP) on SAECG compared to 1 (2%) in controls (p = 0.001). LP were more common in 5 patients with a high-risk phenotype (60% vs 24%) but this was not statistically significant. Twelve patients with BrS (28%) had inferolateral early repolarisation (ER) and 2 (5%) had fractionated QRS (f-QRS), but there were no statistically-significant differences with controls in these parameters. A significant arrhythmia (non-sustained ventricular tachycardia or atrial fibrillation) was seen in 4 patients (9%). CONCLUSIONS This study shows a high prevalence of SAECG abnormalities in children with BrS compared with controls, but this was not significantly associated with a high-risk phenotype.
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Affiliation(s)
- Maria Lopez-Blazquez
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom; Gregorio Marañon Children Hospital, Madrid, Spain
| | - Ella Field
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jennifer Tollit
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Helen Walsh
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Amy Addis
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Nichola French
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Luke Starling
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Juan Pablo Kaski
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom; UCL Institute of Cardiovascular Science, London, United Kingdom.
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Isbister JC, Krahn AD, Semsarian C, Sy RW. Brugada Syndrome: Clinical Care Amidst Pathophysiological Uncertainty. Heart Lung Circ 2020; 29:538-546. [PMID: 31959551 DOI: 10.1016/j.hlc.2019.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 12/11/2022]
Abstract
Brugada syndrome (BrS) is a complex clinical entity with ongoing conjecture regarding its genetic basis, underlying pathophysiology, and clinical management. Within this paradigm of uncertainty, clinicians are faced with the challenge of caring for patients with this uncommon but potentially fatal condition. This article reviews the current understanding of BrS and highlights the "known unknowns" to reinforce the need for flexible clinical practice in parallel with ongoing scientific discovery.
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Affiliation(s)
- Julia C Isbister
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Andrew D Krahn
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, University of Sydney, Sydney, NSW, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Raymond W Sy
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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Aras D, Ozeke O, Cay S, Ozcan F, Topaloglu S. The dividing line of arrhythmogenic right ventricular cardiomyopathy and Brugada syndrome at epicardial ablation era: Limited to or beyond RVOT? Pacing Clin Electrophysiol 2019; 42:771-773. [DOI: 10.1111/pace.13684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Dursun Aras
- Department of Cardiology, Ankara City HospitalHealth Sciences University Ankara Turkey
| | - Ozcan Ozeke
- Department of Cardiology, Ankara City HospitalHealth Sciences University Ankara Turkey
| | - Serkan Cay
- Department of Cardiology, Ankara City HospitalHealth Sciences University Ankara Turkey
| | - Firat Ozcan
- Department of Cardiology, Ankara City HospitalHealth Sciences University Ankara Turkey
| | - Serkan Topaloglu
- Department of Cardiology, Ankara City HospitalHealth Sciences University Ankara Turkey
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Leong KM, Varnava AM. Response to letter to the editor entitled “Should all individuals with a non‐diagnostic arrhythmic electrocardiogram be ordered routinely higher intercostal space electrocardiography?”. Pacing Clin Electrophysiol 2019; 42:492. [DOI: 10.1111/pace.13632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/14/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Kevin M.W. Leong
- National Heart & Lung InstituteImperial College London London UK
- Imperial College Healthcare NHS TrustHammersmith Hospital London UK
| | - Amanda M. Varnava
- National Heart & Lung InstituteImperial College London London UK
- Imperial College Healthcare NHS TrustHammersmith Hospital London UK
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Ozeke O, Cay S, Ozcan F, Topaloglu S, Aras D. Should all individuals with suspected arrhythmias but initially nondiagnostic electrocardiogram be ordered routinely higher intercostal space ECG? Pacing Clin Electrophysiol 2019; 42:489-491. [DOI: 10.1111/pace.13633] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 01/28/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ozcan Ozeke
- Department of Cardiology, Health Sciences UniversityAnkara City Hospital Ankara Turkey
| | - Serkan Cay
- Department of Cardiology, Health Sciences UniversityAnkara City Hospital Ankara Turkey
| | - Firat Ozcan
- Department of Cardiology, Health Sciences UniversityAnkara City Hospital Ankara Turkey
| | - Serkan Topaloglu
- Department of Cardiology, Health Sciences UniversityAnkara City Hospital Ankara Turkey
| | - Dursun Aras
- Department of Cardiology, Health Sciences UniversityAnkara City Hospital Ankara Turkey
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12
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Zakka P, Refaat MM. Sudden cardiac arrest and Brugada syndrome: The search is on for better risk stratification. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:265-266. [DOI: 10.1111/pace.13588] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Patrick Zakka
- Department of Internal Medicine; Emory University Hospital; Atlanta Georgia
| | - Marwan M. Refaat
- Division of Cardiology, Department of Internal Medicine; American University of Beirut Medical Center; Beirut Lebanon
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