PR and QRS intervals in basal electrocardiogram as a useful tool in screening family members for diagnosis of Brugada Syndrome

Funding Acknowledgements

Type of funding sources: None.

Introduction

Diagnosis of Brugada Syndrome (BrS) requires documentation of a spontaneous or pharmacologically induced type 1 Brugada pattern. In individuals with normal basal electrocardiography, screening methods could be challenging. The aim of the study was to detect if other parameters in basal ECG could be a tool to predict the diagnosis of BrS in family members.

Methods

Prospective analysis of 78 patients with family history of BrS and referenced for screening. Basal electrocardiogram was performed in all patients. Patients with spontaneous type 1 Brugada pattern in basal ECG were initially excluded. Definitive diagnosis required a presence of a type 1 ECG pattern or conversion of a type 2 to type 1 following provocative test. The Mann-Whitney U test was used for median comparison between groups as univariate analysis. Analysis of the receiver operating characteristic (ROC) curves were performed to evaluate the predictive values of ECG parameters.

Results

6% (n=5) had spontaneous type 1 Brugada syndrome. 53% were male (n=41); mean age of 28,9±15,3 years. 31% (n=24) had confirmative diagnosis of BrS. 27% (n=21) were carriers of SCN5A mutation. Mean duration of intervals on basal ECG were: RR 871,2±156,0ms; PR 159,3±34,1ms; QRS 91,4±13,4ms; QTc 404,2±32,0. Syncope occurred in 5% of patients (n=5), 94% were asymptomatic.

By univariate analysis the distribution of PR and QRS intervals was significantly different. Wider PR interval was found in patients with BrS (p<0,01) with a median of 200ms (variance of 1269) versus healthy individuals (median of 150ms and variance of 601). Wider QRS intervals were also found in BrS patients compared with healthy individuals (p<0,01) (100ms (288) versus 80ms (204)). The cut-off point, with the most sensitivity (S) and specificity (E) obtained using the Youden index (YI) for PR interval was 170ms (YI 0,5389; Sensitivity (S)≈65% and Specificity(E)≈89%) and for QRS interval was 97ms (YI 0,5148; Sensitivity (S)≈70% and Specificity(E)≈82%).

Conclusion

Higher PR and QRS intervals were associated with BrS diagnosis comparing to healthy family members which may pose a cost-effective screening tool. More studies are needed to validate this hypothesis.

The role of electrocardiographic findings in pulmonary embolism risk assessment

Funding Acknowledgements

Type of funding sources: None.

Introduction

The electrocardiogram (ECG) is helpful in patients (P) with pulmonary embolism (PE), but it is not present in the existing risk prediction tools, such as the Pulmonary Embolism Severity Index (PESI). Intermediate risk PE encompasses a heterogeneous group of P, with different prognoses, some of whom will need fibrinolytic treatment.

This study aims to determine the prognostic impact of ECG in intermediate-risk PE.

Methods

All P admitted for intermediate-risk PE in an Intensive Cardiac Care Unit between 2007 and 2016 were included. P were followed up for two years for all-cause mortality. Clinical and analytical variables, ECG, echocardiographic, and computed tomography (CT), were collected. Statistical analysis used chi-square and Mann-Whitney U tests, binary logistic regressions, Kaplan-Meier curves, and Cox regression.

Results

This study included 209 P: mean age 63±18years; 38.5% male. T-wave inversion in leads V1-V3 was present in 81 (38.8%), S1Q3T3 pattern in 51 (24.4%), incomplete right bundle branch block (RBBB) in 27 (12.9%), and complete RBBB in 22 (10.5%). T-wave inversion in leads V1-V3 was associated with syncope at presentation (p=0.032); presence of echocardiographic right ventricle dilation (p=0.003) and abnormal interventricular septal (IVS) motion (p=0.001). S1Q3T3 pattern was associated with syncope (p=0.028); higher heart rate at admission (p=0.001); higher troponin (p=0.013) and BNP (p=0.010) levels; abnormal IVS motion (p=0.004); and increased CT-derived right-to-left ventricle diameter (RV/LV) ratio (p=0.014). RBBB were associated with syncope (p=0.020); higher troponin and BNP levels (p=0.001); and increased RV/LV ratio (p=0.029). For each increase in the number of these ECG findings, there was an increase in the odds of fibrinolytic treatment (OR 1.573, 95%CI 1.150-2.151, p=0.005), and the number of ECG findings was a predictor of fibrinolysis independently from PESI (OR 1.535, p=0.008).

In survival analysis, T-wave inversion in leads V1-V3 was associated with decreased survival during follow-up (x2=4.398; p=0.036), even after adjustment for PESI (OR 0.322, p=0.041).

Conclusions

ECG findings of PE were associated with clinical, analytical and imagiological risk features. They were also predictors of fibrinolysis, and T-wave inversion in leads V1-V3 was associated with decreased survival after adjustment for PESI. Therefore, in the future, incorporation of ECG findings in risk scores might allow better risk assessment in intermediate-risk PE.

Modified FAST score as a predictor of fibrinolysis in normotensive patients with acute pulmonary embolism

Introduction

Intermediate risk pulmonary embolism (PE) encompass a heterogeneous group of patients with very distinct prognosis. While some patients will only need anticoagulation, in others fibrinolytic therapy (FT) should be considered in order to prevent further hemodynamic decompensation. It is very important to identify the subgroup of intermediate risk PE patients at highest risk of an adverse outcome in whom FT may be needed. Modified FAST score was developed to identify non-high risk PE patients at highest risk of early PE-related complications. This study aims to evaluate if modified FAST score is a predictor of necessity of FT.

Methods

A retrospective analysis of 178 patients admitted for acute PE was performed. Modified FAST score evaluates the presence of syncope (1.5 points), troponin I elevation (1.5 points) and heart rate ≥100bpm (2 points), ranging from 0–5 points (<3 points low risk and ≥3 points intermediate-high risk for adverse in-hospital outcome). PESI score was also calculated for each patient. The Mann-Whitney U was used for comparisons between groups. Binary logistic regressions were used to obtain the odds ratio (OR) for FT of the various variables. ROC curves allowed the comparison of modified FAST and PESI scores.

Results

Mean age was 63±18 years; 61% were female; 8.5% had previous history of venous thromboembolism; 48% of patients had a precipitating factor identified; 58% had signs of right ventricle dilation on echocardiography (echo) and/or chest computed tomography (CCT). 47% had low risk (LR) and 53% had intermediate-high risk (IHR), according to modified FAST score. Mean FAST score was 2.22±1.4.

There were no differences between patients with LR or IHR regarding age, sex and precipitating factor. IHR was associated with dyspnea (p=0.002), lower arterial systolic pressure at admission (p=0.007), higher levels of D-dimer (p=0.013), S1Q3T3 pattern (p=0.001) and right bundle branch block pattern (p=0.005) in electrocardiography and higher right ventricle diameter in echo and CCT (p=0.006).

During hospitalization patients with IHR had more worsening of renal function (p=0.015).

Patients with IRH were submitted more frequently to FT than patients with LR (65% vs 39%; p=0.001). Modified FAST score was a predictor of FT (OR 2.9; 95% CI 1.5–5.5; p<0.001) and was independent of PESI score (OR 2.9; 95% CI 1.5–5.6; p=z0.001). ROC curve analysis revealed a higher area under the curve for modified FAST score comparing to PESI score (0.659 vs 0.497).

Conclusion

IHR modified FAST score was associated with characteristics of poor prognosis in PE. Furthermore, modified FAST score was a predictor of FT in normotensive patients with PE, and was independent of PESI score. Therefore, this score may be useful to select patients with PE that will benefit from FT.

Funding Acknowledgement

Type of funding sources: None.

Bronchial oncocytoma

CONTEXT

Oncocytomas are generally small and present slow growth. Finding of the tumor usually occurs incidentally. Their incidence is higher among male patients. Oncocytomas in mucous bronchial glands are extremely rare.

CASE REPORT

A 35-year-old male who presented bronchial oncocytoma. The tumor was found after bronchoscopy that investigated an atelectasis of the upper left lobe. Histological examination with optical microscopy revealed a mature neoplasm formed by ovoid cells with thin, granular, eosinophilic cytoplasm and small nuclei similar to oncocytes. Electron microscopy showed mitochondrial hyperplasia. A three-year follow-up after thoracotomy followed by lobectomy and removal of the bronchial tumor was uneventful.