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Vacher E, Gourraud JB, Probst V. When to ablate in Brugada and early repolarization syndromes. Expert Rev Cardiovasc Ther 2024; 22:19-26. [PMID: 38427316 DOI: 10.1080/14779072.2024.2326549] [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: 10/05/2023] [Accepted: 02/29/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Mapping advances have expanded both the feasibility and benefits of ablation as a therapeutic approach, including in the treatment of two heart conditions that contribute to sudden cardiac death in young people: Brugada syndrome (BrS) and early repolarization syndrome (ERS). Although these conditions share a number of similarities, debates persist regarding the underlying pathophysiology and origin of the ventricular arrhythmias associated with them. AREAS COVERED By synthesizing available data (PubMed), including current recommendations, pathophysiological insights and case reports, patient registries, our aim is to elucidate and establish the nuanced role of radiofrequency ablation (RFA) in therapeutic management. EXPERT OPINION RFA is a particularly promising approach in BrS, with a proven long-term benefit. Concerning ERS, RFA seems to be interesting at the price of more complex procedures with more nuanced results.
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Affiliation(s)
- Eloi Vacher
- Centre Hospitalier Universitaire d'Angers, Service de Cardiologie, Angers, France
| | - Jean Baptiste Gourraud
- Centre Hospitalier Universitaire de Nantes, Institut du Thorax, Service de Cardiologie, Nantes, France
| | - Vincent Probst
- Centre Hospitalier Universitaire de Nantes, Institut du Thorax, Service de Cardiologie, Nantes, France
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Calò L, Lanza O, Crescenzi C, Parisi C, Panattoni G, Martino A, Rebecchi M, Tarzia P, Ciampi P, Romeo F, Canestrelli S, Silvetti E, De Ruvo E. The value of the 12-lead electrocardiogram in the prediction of sudden cardiac death. Eur Heart J Suppl 2023; 25:C218-C226. [PMID: 37125292 PMCID: PMC10132628 DOI: 10.1093/eurheartjsupp/suad023] [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] [Indexed: 05/02/2023]
Abstract
Sudden cardiac death (SCD) can be caused by several clinical conditions, overt or misconceived, which recognize different pathophysiologies determining the development of fatal arrhythmic events. In the various forms of structural heart disease such as ischaemic heart disease, cardiomyopathies (e.g. hypertrophic cardiomyopathy, dilated cardiomyopathy, and arrhythmogenic cardiomyopathy), channelopathies (e.g. long-QT syndrome, congenital short QT, Brugada syndrome, early repolarization (ER) syndrome, and idiopathic ventricular fibrillation) but also in the apparently healthy subject, the 12-lead electrocardiogram (ECG) has proved, over the years, to be a reliable and readily available method for stratifying the risk of adverse arrhythmic events and consequently SCD. Several electrocardiographic markers have been shown to be associated with adverse outcomes in different types of patients. Although with different sensitivity and specificity in each clinical condition, depolarization abnormalities, such as QRS fragmentation, Q waves, QRS duration, left posterior fascicular block, low QRS voltage, and left ventricular hypertrophy and similarly repolarization abnormalities as ER pattern, T wave alternans, QT interval, and QT dispersion, have shown significant efficacy in predicting SCD. Despite the advancement of techniques especially in the field of imaging, the correct interpretation of the 12-lead ECG remains, therefore, an effective tool for assessing the possible prognostic outcome in terms of arrhythmic risk and SCD in different types of patients.
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Affiliation(s)
- Leonardo Calò
- Corresponding author. Tel: +39 06 23188406, Fax: +39 06 23188410,
| | - Oreste Lanza
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Cinzia Crescenzi
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Cristian Parisi
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Germana Panattoni
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Annamaria Martino
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Marco Rebecchi
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Pierpaolo Tarzia
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Pellegrino Ciampi
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Fabiana Romeo
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Stefano Canestrelli
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Elisa Silvetti
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Ermenegildo De Ruvo
- Division of Cardiology, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
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Aweimer A, Mügge A, Akin I, El-Battrawy I. [Asymptomatic channelopathies : Risk stratification and primary prophylaxis]. Herzschrittmacherther Elektrophysiol 2023; 34:101-108. [PMID: 37103573 DOI: 10.1007/s00399-023-00937-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 04/28/2023]
Abstract
In general, asymptomatic patients with channelopathies are at increased risk of sudden cardiac death (SCD), due to pathogenic variants in genes encoding ion channels that result in pathological ion currents. Channelopathies include long-QT syndrome (LQTS), Brugada syndrome (BrS), catecholaminergic polymorphic ventricular tachycardia (CPVT), and short-QT syndrome (SQTS). In addition to the patient's clinical presentation, history and clinical tests, the main diagnostic tools are electrocardiography and genetic testing to identify known gene mutations. Early and correct diagnosis as well as further risk stratification of affected individuals and their relatives are paramount for prognosis. The recent availability of risk score calculators for LQTS and BrS allows SCD risk to be accurately estimated. The extent to which these improve patient selection for treatment with an implantable cardioverter-defibrillator (ICD) system is currently unknown. In most cases, initiation of basic therapy in asymptomatic patients in the form of avoidance of triggers, which are usually medication or stressful situations, is sufficient and contributes to risk reduction. In addition, there are other risk-reducing prophylactic measures, such as permanent medication with nonselective β‑ blockers (for LQTS and CPVT) or mexiletine for LQTS3. Patients and their family members should be referred to specialized outpatient clinics for individual risk stratification in the sense of primary prophylaxis.
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Affiliation(s)
- Assem Aweimer
- Klinik für Kardiologie und Angiologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Ruhr Universität Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland.
| | - Andreas Mügge
- Klinik für Kardiologie und Angiologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Ruhr Universität Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland
| | - Ibrahim Akin
- I. Medizinische Klinik, Universitätsklinikum Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Ibrahim El-Battrawy
- Klinik für Kardiologie und Angiologie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Ruhr Universität Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 849] [Impact Index Per Article: 424.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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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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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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Salghetti F, de Asmundis C, Sieira J, Coutiño HE, Abugattas JP, Varnavas V, Maj R, Terasawa M, Guimarães Osório T, Stroker E, Capulzini L, Iacopino S, Paparella G, Umbrain V, Poelaert J, Van Dooren S, Brugada P, Chierchia GB, La Meir M. Hybrid thoracoscopic epicardial ablation of right ventricular outflow tract in patients with Brugada syndrome. Heart Rhythm 2019; 16:879-887. [DOI: 10.1016/j.hrthm.2018.12.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Indexed: 11/29/2022]
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Nagayama T, Nagase S, Kamakura T, Wada M, Ishibashi K, Inoue YY, Miyamoto K, Noda T, Aiba T, Takaki H, Sugimachi M, Shimizu W, Noguchi T, Yasuda S, Kamakura S, Kusano K. Clinical and Electrocardiographic Differences in Brugada Syndrome With Spontaneous or Drug-Induced Type 1 Electrocardiogram. Circ J 2019; 83:532-539. [DOI: 10.1253/circj.cj-18-0643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Tomomi Nagayama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
- Department of Cardiovascular Medicine, Fukuoka City Hospital
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tsukasa Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mitsuru Wada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yuko Y. Inoue
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroshi Takaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masaru Sugimachi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Shiro Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Sugrue A, Rohatgi RK, Bos M, Vaidya VR, Asirvatham SJ, Noseworthy PA, Ackerman MJ. Clinical Significance of Early Repolarization in Long QT Syndrome. JACC Clin Electrophysiol 2018; 4:1238-1244. [DOI: 10.1016/j.jacep.2018.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/30/2018] [Accepted: 06/07/2018] [Indexed: 11/16/2022]
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Honarbakhsh S, Providencia R, Lambiase PD. Risk Stratification in Brugada Syndrome: Current Status and Emerging Approaches. Arrhythm Electrophysiol Rev 2018; 7:79-83. [PMID: 29967678 PMCID: PMC6020188 DOI: 10.15420/aer.2018.2.2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/22/2018] [Indexed: 11/04/2022] Open
Abstract
Brugada syndrome (BrS) is one of the most common inherited channelopathies associated with an increased risk of sudden cardiac death. Appropriate use of an ICD in high-risk patients is life-saving. However, there remains a lack of consensus on risk stratification, and even on the diagnosis of BrS itself. Some argue that people with a type 1 Brugada ECG pattern but no symptoms should not be diagnosed with BrS, and guidelines recommend observation without therapy in these patients. Others argue that the presence of a spontaneous (rather than drug-induced) type 1 ECG pattern alone is enough to label them as high-risk for arrhythmic events, particularly if syncope is also present. Syncope and a spontaneous type 1 ECG pattern are the only factors that have consistently been shown to predict ventricular arrhythmic events and sudden cardiac death. Other markers have yielded conflicting data. However, in combination they may have roles in risk scoring models. Epicardial catheter ablation in the right ventricular outflow tract has shown promise in studies as an alternative management option to an ICD, but longer follow-up is required to ensure that the ablation effect is permanent.
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Robyns T, Nuyens D, Vandenberk B, Kuiperi C, Corveleyn A, Breckpot J, Garweg C, Ector J, Willems R. Genotype-phenotype relationship and risk stratification in loss-of-function SCN5A mutation carriers. Ann Noninvasive Electrocardiol 2018; 23:e12548. [PMID: 29709101 DOI: 10.1111/anec.12548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 02/12/2018] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Loss-of-function (LoF) mutations in the SCN5A gene cause multiple phenotypes including Brugada Syndrome (BrS) and a diffuse cardiac conduction defect. Markers of increased risk for sudden cardiac death (SCD) in LoF SCN5A mutation carriers are ill defined. We hypothesized that late potentials and fragmented QRS would be more prevalent in SCN5A mutation carriers compared to SCN5A-negative BrS patients and evaluated risk markers for SCD in SCN5A mutation carriers. METHODS We included all SCN5A loss-of-function mutation carriers and SCN5A-negative BrS patients from our center. A combined arrhythmic endpoint was defined as appropriate ICD shock or SCD. RESULTS Late potentials were more prevalent in 79 SCN5A mutation carriers compared to 39 SCN5A-negative BrS patients (66% versus 44%, p = .021), while there was no difference in the prevalence of fragmented QRS. PR interval prolongation was the only parameter that predicted the presence of a SCN5A mutation in BrS (OR 1.08; p < .001). Four SCN5A mutation carriers, of whom three did not have a diagnostic type 1 ECG either spontaneously or after provocation with a sodium channel blocker, reached the combined arrhythmic endpoint during a follow-up of 44 ± 52 months resulting in an annual incidence rate of 1.37%. CONCLUSION LP were more frequently observed in SCN5A mutation carriers, while fQRS was not. In SCN5A mutation carriers, the annual incidence rate of SCD was non-negligible, even in the absence of a spontaneous or induced type 1 ECG. Therefore, proper follow-up of SCN5A mutation carriers without Brugada syndrome phenotype is warranted.
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Affiliation(s)
- Tomas Robyns
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Dieter Nuyens
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Bert Vandenberk
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Cuno Kuiperi
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Anniek Corveleyn
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Jeroen Breckpot
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Christophe Garweg
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Joris Ector
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Rik Willems
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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Rattanawong P, Riangwiwat T, Prasitlumkum N, Limpruttidham N, Kanjanahattakij N, Chongsathidkiet P, Vutthikraivit W, Chung EH. Baseline fragmented QRS increases the risk of major arrhythmic events in Brugada syndrome: Systematic review and meta-analysis. Ann Noninvasive Electrocardiol 2018; 23:e12507. [PMID: 29030919 PMCID: PMC6931739 DOI: 10.1111/anec.12507] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 09/20/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Fragmented QRS reflects disturbances in the myocardium predisposing the heart to ventricular tachyarrhythmias. Recent studies suggest that fragmented QRS (fQRS) is associated with major arrhythmic events in Brugada syndrome. However, a systematic review and meta-analysis of the literature has not been done. We assessed the association between fQRS and major arrhythmic events in Brugada syndrome by a systematic review of the literature and a meta-analysis. METHODS We comprehensively searched the databases of MEDLINE and EMBASE from inception to May 2017. Included studies were published prospective or retrospective cohort studies that compared major arrhythmic events (ventricular fibrillation, sustained ventricular tachycardia, sudden cardiac arrest, or sudden cardiac death) in Brugada syndrome with fQRS versus normal QRS. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. RESULTS Nine studies from January 2012 to May 2017 were included in this meta-analysis involving 2,360 subjects with Brugada syndrome (550 fQRS and 1,810 non-fQRS). Fragmented QRS was associated with major arrhythmic events (pooled risk ratio =3.36, 95% confidence interval: 2.09-5.38, p < .001, I2 = 50.9%) as well as fatal arrhythmia (pooled risk ratio =3.09, 95% confidence interval: 1.40-6.86, p = .005, I2 = 69.7%). CONCLUSIONS Baseline fQRS increased major arrhythmic events up to 3-fold. Our study suggests that fQRS could be an important tool for risk assessment in patients with Brugada syndrome.
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Affiliation(s)
- Pattara Rattanawong
- University of Hawaii Internal Medicine Residency ProgramHonoluluHIUSA
- Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | | | | | | | | | | | | | - Eugene H. Chung
- Department of Internal MedicineUniversity of Michigan Medical SchoolMichigan MedicineAnn ArborMIUSA
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Pérez-Riera AR, Barbosa-Barros R, Shenasa M. Electrocardiographic Markers of Sudden Cardiac Death (Including Left Ventricular Hypertrophy). Card Electrophysiol Clin 2017; 9:605-629. [PMID: 29173405 DOI: 10.1016/j.ccep.2017.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Although the electrocardiograph (ECG) was invented more than 100 years ago, it remains the most commonly used test in clinical medicine. It is easy to perform, relatively cheap, and results are readily available. Interpretation, however, needs expertise and knowledge. New data, phenomenon, and syndromes are continually discovered by the ECG. It is important to differentiate between normal and abnormal ECGs first and then try to correlate the findings with clinical pathologies. Furthermore, the ECG is an integral part of the screening model for a variety of conditions such as channelopathies, athletes, preoperative risk profile, and remains the cardiologist's best friend.
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Affiliation(s)
- Andrés Ricardo Pérez-Riera
- Design of Studies and Scientific Writing Laboratory in the ABC School of Medicine, ABC Foundation, Av. Príncipe de Gales, 821 - Vila Principe de Gales, Santo André, São Paulo 09060-650, Brazil; Ambulatorio de cardiologia do Hospital do Coração, R. Des. Eliseu Guilherme, 147 - Paraiso, São Paulo, São Paulo 04004-030, Brazil
| | - Raimundo Barbosa-Barros
- Coronary Center of the Hospital de Messejana Dr Carlos Alberto Studart Gomes, Av. Frei Cirilo, 3480, Fortaleza, Ceará 60840-285, Brazil
| | - Mohammad Shenasa
- Department of Cardiovascular Services, Heart and Rhythm Medical Group, O'Connor Hospital, 105 North Bascom Avenue, Suite 204, San Jose, CA 95128, USA.
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Cerrone M. Controversies in Brugada syndrome. Trends Cardiovasc Med 2017; 28:284-292. [PMID: 29254832 DOI: 10.1016/j.tcm.2017.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 11/16/2017] [Accepted: 11/21/2017] [Indexed: 12/19/2022]
Abstract
The Brugada syndrome is an inherited channelopathy associated with increased risk of ventricular arrhythmias and sudden death, often occurring during sleep or resting conditions. Although this entity has been described more than 20 years ago, it remains one of the most debated among channelopathies, with several open questions on its genetic substrate, arrhythmia mechanisms, and clinical management. Studies on the genetics and physiopathology bases of the Brugada syndrome have opened novel investigative pathways and concepts that are now entering the field of cardiovascular genetics and are applied to other inherited arrhythmias. In this perspective, Brugada syndrome can be seen as an example on how basic science discoveries have influenced clinical management and led to novel therapeutic approaches.
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Affiliation(s)
- Marina Cerrone
- Cardiovascular Genetics Program, Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY.
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15
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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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16
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Lee A, Kohler H, Wright D, Haqqani HM. Epicardial Brugada syndrome ablation unmasking inferior J waves. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1308-1312. [DOI: 10.1111/pace.13095] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 03/17/2017] [Accepted: 04/12/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Adam Lee
- Department of Cardiology; The Prince Charles Hospital; Brisbane Australia
- School of Medicine; The University of Queensland; Brisbane Australia
| | | | - Daniel Wright
- Department of Cardiology; The Prince Charles Hospital; Brisbane Australia
| | - Haris M. Haqqani
- Department of Cardiology; The Prince Charles Hospital; Brisbane Australia
- School of Medicine; The University of Queensland; Brisbane Australia
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17
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Morita H, Watanabe A, Morimoto Y, Kawada S, Tachibana M, Nakagawa K, Nishii N, Ito H. Distribution and Prognostic Significance of Fragmented QRS in Patients With Brugada Syndrome. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.116.004765. [DOI: 10.1161/circep.116.004765] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 02/14/2017] [Indexed: 11/16/2022]
Abstract
Background—
Fragmented QRS complexes (fQRS) in the right precordial leads are associated with occurrence of ventricular fibrillation (VF) in Brugada syndrome. Recently, epicardial mapping has revealed abnormal electrograms at the right ventricular (RV) outflow tract and inferior region of the right ventricle. fQRS may reflect the extent of the area of abnormal potentials, but whether the distribution of fQRS has prognostic value is not known.
Methods and Results—
We evaluated the existence of fQRS in 456 patients with Brugada syndrome, including 117 patients with syncope and 23 patients with VF. The region of fQRS was defined as inferior (II, III, and aVF), lateral (I, aVL, and V5 and V6), anterior (V3 and V4), RV (V1 and V2), and RV outflow tract (V1 and V2 at the third intercostal space). fQRS were present in 229 patients (RV outflow tract in 175, inferior in 135, RV in 90, and lateral in 16 patients). During follow-up (mean 91 months), 39 patients experienced VF. In univariable analyses, fQRS in any distribution and fQRS in each region excluding the RV were associated with VF. Multivariable analysis showed that fQRS in the inferior (hazard ratio, 3.9; confidence interval, 1.9–8.5), lateral (hazard ratio, 3.5; confidence interval, 1.2–8.2), and RV outflow tract (hazard ratio, 2.5; confidence interval, 1.2–5.6) were associated with VF events. The presence of multiple regions of fQRS was associated with worse prognosis.
Conclusions—
The distribution of fQRS is associated with prognosis in Brugada syndrome, further supporting the association of fQRS and arrhythmia substrate.
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Affiliation(s)
- Hiroshi Morita
- From the Department of Cardiovascular Therapeutics (H.M., N.N.) and Department of Cardiovascular Medicine (A.W., Y.M., S.K., M.T., K.N., H.I.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Atsuyuki Watanabe
- From the Department of Cardiovascular Therapeutics (H.M., N.N.) and Department of Cardiovascular Medicine (A.W., Y.M., S.K., M.T., K.N., H.I.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Yoshimasa Morimoto
- From the Department of Cardiovascular Therapeutics (H.M., N.N.) and Department of Cardiovascular Medicine (A.W., Y.M., S.K., M.T., K.N., H.I.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Satoshi Kawada
- From the Department of Cardiovascular Therapeutics (H.M., N.N.) and Department of Cardiovascular Medicine (A.W., Y.M., S.K., M.T., K.N., H.I.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Motomi Tachibana
- From the Department of Cardiovascular Therapeutics (H.M., N.N.) and Department of Cardiovascular Medicine (A.W., Y.M., S.K., M.T., K.N., H.I.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Koji Nakagawa
- From the Department of Cardiovascular Therapeutics (H.M., N.N.) and Department of Cardiovascular Medicine (A.W., Y.M., S.K., M.T., K.N., H.I.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Nobuhiro Nishii
- From the Department of Cardiovascular Therapeutics (H.M., N.N.) and Department of Cardiovascular Medicine (A.W., Y.M., S.K., M.T., K.N., H.I.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
| | - Hiroshi Ito
- From the Department of Cardiovascular Therapeutics (H.M., N.N.) and Department of Cardiovascular Medicine (A.W., Y.M., S.K., M.T., K.N., H.I.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Japan
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18
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Intracoronary acetylcholine application as a possible probe inducing J waves in patients with early repolarization syndrome. J Arrhythm 2017; 33:424-429. [PMID: 29021844 PMCID: PMC5634679 DOI: 10.1016/j.joa.2016.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/18/2016] [Accepted: 12/27/2016] [Indexed: 12/11/2022] Open
Abstract
Acetylcholine is widely used for a diagnostic provocation test of coronary spasm in patients with vasospastic angina. Acetylcholine usually induces coronary vasodilatation mediated by muscarinic receptor activation, but sometimes it evokes vasoconstriction of coronary arteries where the endothelium is damaged. Early repolarization syndrome is characterized by a J wave observed at the end of the QRS complex in a surface electrocardiogram. The J wave is attributed to the transmural voltage gradient at the early repolarization phase across the ventricular wall, which stems mainly from prominent transient outward current in the epicardium, but not in the endocardium. Transient high-dose application of acetylcholine into the epicardial coronary arteries provides a unique opportunity to augment net outward current, selectively, in the ventricular epicardium and unmask the J wave, irrespective of the cardiac ischemia based on coronary spasm. Acetylcholine augments cardiac membrane potassium conductance by enhancing acetylcholine-activated potassium current directly and by activating adenosine triphosphate-sensitive potassium current, in addition to the reduced sodium and calcium currents in the setting of severe ischemia due to vasospasm. However, the role of acetylcholine as an arrhythmogenic probe of the J wave induction in patients with suspected early repolarization syndrome warrants future prospective study.
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Sieira J, Brugada P. Management of Brugada Syndrome 2016: Should All High Risk Patients Receive an ICD? All High-Risk Patients Should Receive an Implantable Cardiac Defibrillator. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.116.004195. [PMID: 27906652 DOI: 10.1161/circep.116.004195] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/26/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Juan Sieira
- From the Heart Rhythm Management Centre, UZ Brussel-VUB, Brussels, Belgium
| | - Pedro Brugada
- From the Heart Rhythm Management Centre, UZ Brussel-VUB, Brussels, Belgium.
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Abstract
Since the first description of the Brugada syndrome (BS) in 1992, scientific progress in the understanding of this disease has been enormous; at the same time more and more individuals with the disease have been diagnosed. The profile of patients with BS has changed with more asymptomatic individuals and less expressive clinical features. Asymptomatic BS individuals are at lower arrhythmic risk than those presenting with syncope or sudden cardiac death (SCD). The event incidence rate is around 0.5 % per year; this figure is relevant due to the fact that individuals have a long life expectancy and are otherwise healthy. As a result of the risk of SCD, risk stratification is of utmost importance. As the implantation of a cardioverter defibrillator is the main treatment for those patients at higher risk, benefits and long-term potential risks have to be adequately considered. Some risk factors, such as spontaneous type 1 electrocardiogram (ECG) pattern, are widely accepted, whilst for others contradictory data are present. Furthermore, novel risk factors are now available that might help in the management of BS. The presence of a spontaneous type 1 ECG pattern, history of sinus node dysfunction and inducible ventricular arrhythmias during programmed electrical stimulation of the heart allow us to risk stratify these patients.
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Affiliation(s)
- Juan Sieira
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Pedro Brugada
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
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