Ripolarizzazione precoce.

Transcription

1 Controversia: impianto di defibrillatore in prevenzione primaria Caso clinico: Ripolarizzazione precoce. Sindrome di Brugada Non così innocente come si pensava Torino, 31 marzo 2017 Carla Giustetto Carla Giustetto Divisione di Cardiologia Divisione Università di Cardiologia Torino Ospedale S.Giovanni Battista -Università di Torino Ospedale Città della Salute e della Scienza

2 Brugada electrocardiographic pattern: diagnosis J point 2mm Coved-type ST segment elevation Negative T wave 1 right precordial lead Spontaneous or after sodium-channel blockers V1 V2 Only type 1 ECG is diagnostic Ø increased risk of ventricular arrhythmias which cause may syncope or sudden death, also as first manifestation Wilde, Circulation 2002;106; ; HRS/EHRA/APHRS expert consensus statement. Europace 2013; 15:

3 A 45 years old man: traumatic syncope, which occurred after awakening at 6.30 a.m, while he was in the bathroom, with doubtful prodromes 1st ECG: sinus rhythm, normal conduction, non-significant ST-T alterations

4 Head-up tilt test (HUTT) Tilt test was negative but ST segment in V1-V2 with a type 2 Brugada pattern was recorded V1 V2

5 Pt with traumatic syncope + suspect Brugada ECG (type 2) V1 V2 Which investigations are reasonable/recommended? ECG with V1-V2 at 2 nd and 3 rd intercostal space (ICS)

6 Correlation between RVOT position and exploring electrodes RVOT is the section of the myocardium where I to is more represented and this area in the chest is variable between the 2 nd and 4 th ICS ICS= intercostal space Nagase et al, JACC 2010, 56

7 ECG was recorded with V1-V2 at a higher intercostal space à in this case it remained doubtful, still not diagnostic ECG 4th ICS V1 2 ICS V2 2 ICS

8 Which investigations are reasonable/recommended? Pt with traumatic syncope + suspect Brugada ECG pattern (type 2) ECG with V1-V2 at 2 nd and 3 rd intercostal space type 2 Brugada ECG Drug challenge with sodium channel blockers

9 Pharmacological challenge with Na+-channel blockers was performed Basal ECG V1 V2 Ajmaline infusion (1mg/kg in 5 min) V1 V2 V3 V4 V1 - II space V2 - II space V1 - II space V2 - II space

10 mean f-up 48±48 months

11 Sacher F, et al, Heart Rhythm 2012; 9: pts with syncope (28%) group 1 (40%) arrhytmic syncope: absence of prodromes and fast return to consciousness 6 ICD shock for VF 5.5% per year group 2 (30%) neurocardiogenic syncope: prodromes (sweating, nausea, pallor) and longer time of unconsciousness f-up 65 months group 3 (30%) uncertain origin of syncope loop recorder 35% No arrhythmic events, but recurrence of syncope similar to the initial one

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13 Results: arrhythmic events at follow-up Mean follow-up of 62±48 months Freedom from arrhythmic events 1 0,95 0,9 0,85 0,8 0,75 0,7 0,65 G1 vs G2, p=0.02 G1 vs Asympt, p=0.58 G2 vs Asympt, p < neurally-mediated Group1 Group2 asymptomatic neurally-mediated unexplained 1% (0.2% person-year) 2% (0.3% person-year) 9% (1.8% person-year) 0, time (years) G G Asympt

14 Summary ü45 years old man üsyncope of uncertain origin üdrug induced type 1 Brugada ECG pattern Which is the appropriate treatment for this patient? What does literature report? What do guidelines recommend?

15 No syncope, nor type 1 Circulation 2002;105:1342 Italian Registry 200 pts Asymptomatic spontaneous type 1 Syncope + induced type 1 Syncope + spontaneous type 1 HR 6.4 for risk of cardiac arrest

16 Circulation 2010;121: 635 Symptoms and spontaneous type 1 ECG were predictors of arrhythmic events 1029 pz - median f-up 32 months HR=11 for SD (p<0.001) and HR=3.4 for syncope (p=0.002) HR=2.1 (p=0.01)

17 12-lead 24-hour Holter monitoring showed presence of intermittent spontaneous type 1 Brugada pattern V1 - II space h. 4:12 pm h. 11:44 pm h. 6:33 am h. 8:20 am h. 1:08 pm V2 - II space V1 standard V2 standard V5 V6

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19 Brugada Piedmont Registry 684 patients 12 Lead - 24 hour Holter 251 patients % 70% 30% Persistent type 1 Intermittent type 1 No type 1 spontaneous type 1 at basal ECG (group 1) drug-induced type 1 (group 2) % 57% 31% group 1 20% group 2 Cerrato, Giustetto et al. Am J Cardiol 2015; 115: 52-56

20 Circadian fluctuations of Brugada ECG pattern N of 12L-Holter with type 1 BrECG p< midnight-6 am 6 am-12 noon 12 noon-6 pm 6 pm-12 midnight Cerrato, Giustetto et al. Am J Cardiol 2015; 115: 52-56

21 12 lead Holter monitoring: ü allows to identify, in group 2, at least 20% of subjects with spontaneous type 1, who would have been considered at low risk, based only on periodic 12-lead ECGs ü might be the first screening test, in alternative to pharmacological test, particularly in children, in presence of a borderline-diagnostic basal ECG and in the evaluation of family members Am J Cardiol 2015; 115: 52-56

22 Summary ü45 years old man üsyncope of uncertain origin üdrug induced type 1 Brugada ECG pattern and ü spontaneous type 1 documented at f-up Which is the appropriate treatment for this patient? What do guidelines recommend? What does literature report?

23 2015 ESC GUIDELINES DIFFERENT OPINIONS

24 Eventi aritmici al follow-up in relazione al risultato dello studio elettrofisiologico 135 pazienti 0/ 89 7/ 46 (15%) 135 patients Follow-up: 30±21 mesi

25 Results Role of of EP-study study in in Brugada Brugada pts pts (overall (overall population) P = 0.05 Probst et al, FINGER Registry, Circulation 2010;121: 635

26 Role of EP-study in Brugada patients with syncope 1029 pts median f-up 32 months Probst et al, FINGER Registry, Circulation 2010;121: 635

27 Role of electrophysiological study in pts with UNEXPLAINED SYNCOPE Mean f-up of 62±48 months 0 events 27% 5.2% per year Giustetto et al. Intern J Cardiol 2017, in press

28 Spontaneous type 1 ECG N= 97 Events 7 (7%) 1.4 per 100 person-year Unexplained syncope N= 51 Events 6 (12%) 2.3 per 100 person-year EPS done N= 39 (76%) EPS not done N= 12 (24%) ICD + N= 7 Events 0 ICD - N= 5 Events 0 EPS + N= 21 (53%) EPS - N= 18 (47%) ICD + N= 21 ICD - N= 0 ICD + N= 5 ICD - N= 13 Events 6 (29%) Events - Events 0 Events 0 Giustetto et al. Intern J Cardiol 2017

29 Syncope of uncertain origin + Brugada ECG Electrophysiologic study (EPS) pos neg ICD in primary prevention follow-up with implantable loop recorder

30 In our patient Electrophysiologic study (EPS) resulted in induction of VF Considering the syncope of uncertain origin, spontaneous type 1 ECG and positive EPS, an ICD was implanted

31 One year after The patient experienced the first episode of VF which was recognised and interrupted by ICD shock. He experienced other 3 episodes of VF in 2 years of follow-up 4 3 FV ICD Hydroquinidine 2 1 0

32 Conclusions 1. Spontaneous and drug-induced type 1 have different prognosis 2. >20% of drug-induced become spontaneous type 1 during followup (serial ECG and 12-lead 24-hour Holter monitoring) 3. Brugada patients with syncope of uncertain origin have a high risk of arrhythmic events at follow-up. 4. EP-study has a predominant role in this group to identify the patients with indication to ICD implant in primary prevention

33 Probably non-arrhythmicsyncope : Good prognosis, similar to asymptomatic subjects Spontaneous type 1 ECG EPS + EPS - + hydroquinidine loop recorder follow-up