Caso clinico: Palpitazioni, Sincope e Brugada Diana Solari Centro Aritmologico e Syncope Unit, Lavagna. Santa Margherita Ligure, 4 aprile 2014

Transcription

1 Caso clinico: Palpitazioni, Sincope e Brugada Diana Solari Centro Aritmologico e Syncope Unit, Lavagna Santa Margherita Ligure, 4 aprile 2014

2 Anamnesi Uomo di 48 anni Pattern ECG tipo 2 Brugada Consigliato impianto di defibrillatore automatico presso altro Centro

3 Anamnesi Episodi ricorrenti di cardiopalmo notturno Sincopi recidivanti con lunghi prodromi neurovegetativi, con traumi contusivi minori Familiarità negativa per malattie aritmiche (MCI) Assenza di cardiopatia strutturale Holter ECG delle 24 ore negativo

4 ICD In Brugada syndrome ICD therapy should be considered in patients with in patients with spontaneous type I ECG and unexplained syncope ESC Guidelines on Management of Syncope - Version 2009 symptomatic patients with recurrent syncope, agonal respiration at night during sleep or unknown seizures are at risk of dying suddenly without protection and have a Class I indication for ICD treatment Brugada Syndrome Two Decades of Progress Veerakul G. et al. circj.cj

5 Cosa fare? Test alla flecainide? Studio elettrofisiologico? Impianto loop recorder? Follow-up clinico?

6 Stratificazione ECG Subjects at highest risk are those with a spontaneous type 1 ECG and at least two risk factors (including syncope, family history of SD, and positive EPS); the remainder are at low risk. Risk stratification in individuals with the Brugada type 1 ECG pattern without previous cardiac arrest: usefulness of a combined clinical and electrophysiologic approach. Delise et al, European Heart Journal (2011) 32,

7 Test alla flecainide In asymptomatic individuals with a non-diagnostic Br-ECG, the incidence of events is low regardless of the sodium channel blocker test result while in symptomatic patients a positive sodium-channel blocker test result is associated with an adverse arrhythmic outcome and may contribute to risk stratification. Kaplan-Meier analysis of freedom from adverse events stratified by using the sodium-channel blocker test result in symptomatic (A) and asymptomatic (B) individuals. Should all individuals with a nondiagnostic Brugada-electrocardiogram undergo sodium-channel blocker test? Zorzi A. et al. Heart Rhythm, Vol 9, No 6, June 2012

8 SEF VT/VF inducibility is unable to identify high-risk patients, whereas the presence of a spontaneous type I ECG, history of syncope, ventricular effective refractory period 200 ms, and QRS fragmentation seem useful to identify candidates for prophylactic implantable cardioverter defibrillator. Risk Stratification in Brugada Syndrome Results of the PRELUDE (Programmed ELectrical stimulation predictive value) Registry Priori et al. J Am Coll Cardiol 2012;59:37 45)

9 ILR In Brugada syndrome, in the absence of type I pattern, consider ILR ESC Guidelines on Management of Syncope - Version 2009

10 Impianto di loop recorder Dopo 3 anni di monitoraggio ( ) il paziente ha presentato 65 episodi documentati di palpitazioni e 4 sincopi documentate (durante febbre, post minzionale, post prandium)

11 Documentazione ILR durante palpitazioni (monitoraggio remoto)

12 Documentazione ILR durante episodio sincopale (monitoraggio remoto)

13 Diagnosi finale Cardiopalmo non aritmico Sincopi neuromediate

14 Terapia Rassicurazione Manovre isometriche di contropressione Hand grip Arm (muscle) tensing

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16 11 patients with Type 1 ECG pattern (9 symptomatic, 5 spontaneous Type 1 ECG pattern. 8 recurrence of symptoms Follow-up 33 months 4 pts bradycardia (2 AVB, 2 SB); 6 vasovagal syncopes; 2 epilepsy. no ventricular arrhythmia Conclusions: The use of ILR should be considered in selected patients with atypical syncope and spontaneous or transient Type 1 ECG pattern Kubala M, et al. Europace 2011;14:

17 Possibilità future Impianto di pacemaker se sincopi recidivanti asistoliche con impatto sulla qualità della vita

18 ECG ECG basale: pattern tipo 2 Brugada ECG eseguito posizionando V1 V2 V3 al secondoterzo spazio intercostale: non evidenza di pattern tipo 1.

19 Impianto di loop recorder Implantable Loop Recorder and syncope: indications Class I, B ECG monitoring is indicated in patients who have clinical or ECG features suggesting arrhythmic syncope Class I, B An early phase of evaluation in pts with recurrent syncope of uncertain origin, no high risk criteria and high likelihood of recurrence Class I, B High risk patients in whom a comprehensive evaluation did not demostrate a cause of syncope or lead a specific treatment ESC Guidelines on Management of Syncope Update 2009

20 Impianto di loop recorder Indications of Implantable Loop Recorder other than syncope: ESC guidelines 2009: No recommendation EHRA Position Paper 2009: Class II, B ILR may be indicated in patients with T-LOC of uncertain syncopal origin in order to definitely exclude an arrhythmic mechanism (Level of evidence C)

21 Test alla flecainide Bloccante canali del sodio Clinicamente usato per smascherare ECG diagnostico per S. Brugada (tipo 1, a tenda) in pazienti con ECG non diagnostici (tipo 2 e 3, a sella) BASALE FLECAINIDE 140 MG EV