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Russo V, Caturano A, Migliore F, Guerra F, Francia P, Nesti M, Conte G, Perini AP, Mascia G, Albani S, Marchese P, Santobuono VE, Dendramis G, Rossi A, Attena E, Ghidini AO, Sciarra L, Palamà Z, Baldi E, Romeo E, D'Onofrio A, Nigro G. Long-term clinical outcomes of patients with drug-induced type 1 Brugada electrocardiographic pattern: A nationwide cohort registry study. Heart Rhythm 2024; 21:555-561. [PMID: 38242222 DOI: 10.1016/j.hrthm.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND There are limited real-world data on the extended prognosis of patients with drug-induced type 1 Brugada electrocardiogram (ECG). OBJECTIVE We assessed the clinical outcomes and predictors of life-threatening arrhythmias in patients with drug-induced type 1 Brugada ECG. METHODS This multicenter retrospective study, conducted at 21 Italian and Swiss hospitals from July 1997 to May 2021, included consecutive patients with drug-induced type 1 ECG. The primary outcome, a composite of appropriate ICD therapies and sudden cardiac death, was assessed along with the clinical predictors of these events. RESULTS A total of 606 patients (mean age 49.7 ± 14.7 years; 423 [69.8%] men) were followed for a median of 60.3 months (interquartile range 23.0-122.4 months). Nineteen patients (3.1%) experienced life-threatening arrhythmias, with a median annual event rate of 0.5% over 5 years and 0.25% over 10 years. The SCN5A mutation was the only predictor of the primary outcome (hazard ratio 4.54; P = .002), whereas a trend was observed for unexplained syncope (hazard ratio 3.85; P = .05). In patients who were asymptomatic at presentation, the median annual rate of life-threatening arrhythmias is 0.24% over 5 years and increases to 1.2% if they have inducible ventricular fibrillation during programmed ventricular stimulation. CONCLUSION In patients with drug-induced type 1 Brugada ECG, the annual risk of life-threatening arrhythmias is low, with the SCN5A mutation as the only independent predictor. Unexplained syncope correlated with worse clinical outcomes. Ventricular fibrillation inducibility at programmed ventricular stimulation significantly increases the median annual rate of life-threatening arrhythmias from 0.24% to 1.2% over 5 years.
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Affiliation(s)
- Vincenzo Russo
- Division of Cardiology, Department of Medical Translational Sciences University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Alfredo Caturano
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Federico Guerra
- Azienda Ospedaliera Universitaria Ospedali Riuniti Ancona, Ancona, Italy
| | - Pietro Francia
- Azienda Ospedaliero-Universitaria Sant'Andrea, Rome, Italy
| | - Martina Nesti
- Cardiovascular and Neurological Department, Ospedale San Donato, Arezzo, Italy
| | - Giulio Conte
- Cardiocentro Ticino Foundation, Lugano, Switzerland
| | | | | | | | | | - Vincenzo Ezio Santobuono
- Cardiology Unit, Department of Interdisciplinary Medicine and Policlinico of Bari, University of Bari "Aldo Moro", Bari, Italy
| | - Gregory Dendramis
- Cardiology Unit, Clinical and Interventional Arrhythmology, ARNAS, Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
| | | | | | | | | | | | | | - Emanuele Romeo
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Monaldi Hospital, Naples, Italy
| | - Antonio D'Onofrio
- Monaldi Hospital, Departmental Unit of Electrophysiology, Evaluation and Treatment of Arrhythmias, Naples, Italy
| | - Gerardo Nigro
- Division of Cardiology, Department of Medical Translational Sciences University of Campania "Luigi Vanvitelli", Naples, Italy
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Gaita F, Cerrato N, Giustetto C. Can an implantable loop recorder improve risk stratification and appropriate management in Brugada syndrome? Eur Heart J 2024; 45:1266-1268. [PMID: 38527218 DOI: 10.1093/eurheartj/ehae136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Affiliation(s)
- Fiorenzo Gaita
- Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Natascia Cerrato
- Division of Cardiology, Cardinal G. Massaia Hospital, Asti, Italy
| | - Carla Giustetto
- Department of Medical Sciences, University of Turin, Turin, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
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Bergonti M, Sacher F, Arbelo E, Crotti L, Sabbag A, Casella M, Saenen J, Rossi A, Monaco C, Pannone L, Compagnucci P, Russo V, Heller E, Santoro A, Berne P, Bisignani A, Baldi E, Van Leuven O, Migliore F, Marcon L, Dagradi F, Sfondrini I, Landra F, Comune A, Cespón-Fernández M, Nesti M, Santoro F, Magnocavallo M, Vicentini A, Conti S, Ribatti V, Brugada P, de Asmundis C, Brugada J, Tondo C, Schwartz PJ, Haissaguerre M, Auricchio A, Conte G. Implantable loop recorders in patients with Brugada syndrome: the BruLoop study. Eur Heart J 2024; 45:1255-1265. [PMID: 38445836 PMCID: PMC10998731 DOI: 10.1093/eurheartj/ehae133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/09/2024] [Accepted: 02/19/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND AND AIMS Available data on continuous rhythm monitoring by implantable loop recorders (ILRs) in patients with Brugada syndrome (BrS) are scarce. The aim of this multi-centre study was to evaluate the diagnostic yield and clinical implication of a continuous rhythm monitoring strategy by ILRs in a large cohort of BrS patients and to assess the precise arrhythmic cause of syncopal episodes. METHODS A total of 370 patients with BrS and ILRs (mean age 43.5 ± 15.9, 33.8% female, 74.1% symptomatic) from 18 international centers were included. Patients were followed with continuous rhythm monitoring for a median follow-up of 3 years. RESULTS During follow-up, an arrhythmic event was recorded in 30.7% of symptomatic patients [18.6% atrial arrhythmias (AAs), 10.2% bradyarrhythmias (BAs), and 7.3% ventricular arrhythmias (VAs)]. In patients with recurrent syncope, the aetiology was arrhythmic in 22.4% (59.3% BAs, 25.0% VAs, and 15.6% AAs). The ILR led to drug therapy initiation in 11.4%, ablation procedure in 10.9%, implantation of a pacemaker in 2.5%, and a cardioverter-defibrillator in 8%. At multivariate analysis, the presence of symptoms [hazard ratio (HR) 2.5, P = .001] and age >50 years (HR 1.7, P = .016) were independent predictors of arrhythmic events, while inducibility of ventricular fibrillation at the electrophysiological study (HR 9.0, P < .001) was a predictor of VAs. CONCLUSIONS ILR detects arrhythmic events in nearly 30% of symptomatic BrS patients, leading to appropriate therapy in 70% of them. The most commonly detected arrhythmias are AAs and BAs, while VAs are detected only in 7% of cases. Symptom status can be used to guide ILR implantation.
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Affiliation(s)
- Marco Bergonti
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete 48, CH-6900 Lugano, Switzerland
| | - Frederic Sacher
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L’Institut de Rythmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Lia Crotti
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Departement of Medicine and Surgery, University Milano Bicocca, Milan, Italy
| | - Avi Sabbag
- The Davidai Center for Rhythm Disturbances and Pacing, Chaim Sheba Medical Center, Tel Hashomer and the faculty of medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital ‘Ospedali Riuniti’, Ancona, Italy
- Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Johan Saenen
- Department of Cardiology, University Hospital Antwerp, Edegem, Belgium
| | - Andrea Rossi
- Arrhythmology Division, Fondazione Gabriele Monasterio CNR-Regione Toscana, via Giuseppe Moruzzi, Pisa, Italy
| | - Cinzia Monaco
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L’Institut de Rythmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital ‘Ospedali Riuniti’, Ancona, Italy
| | - Vincenzo Russo
- Cardiology Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’, Monaldi Hospital, Naples, Italy
| | - Eyal Heller
- The Davidai Center for Rhythm Disturbances and Pacing, Chaim Sheba Medical Center, Tel Hashomer and the faculty of medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amato Santoro
- Division of Cardiology, Cardio Thoracic and Vascular Department, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Paola Berne
- Department of Cardiology, Ospedale Santissima Annunziata, University of Sassari, Sassari, Italy
| | - Antonio Bisignani
- Institute of Cardiology, Catholic University of the Sacred Heart, Roma, Italy
| | - Enrico Baldi
- Arrhythmia and Electrophysiology, Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Federico Migliore
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Lorenzo Marcon
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgery and Dentist Sciences, University of Milan, Milan, Italy
| | - Federica Dagradi
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Irene Sfondrini
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete 48, CH-6900 Lugano, Switzerland
| | - Federico Landra
- Arrhythmology Division, Fondazione Gabriele Monasterio CNR-Regione Toscana, via Giuseppe Moruzzi, Pisa, Italy
- Division of Cardiology, Cardio Thoracic and Vascular Department, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Angelo Comune
- Cardiology Unit, Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’, Monaldi Hospital, Naples, Italy
| | - María Cespón-Fernández
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Martina Nesti
- Division of Cardiology, Cardio Thoracic and Vascular Department, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Francesco Santoro
- Cardiothoracic Department, Cardiology Unit, Policlinico Riuniti, Foggia, Italy
| | | | - Alessandro Vicentini
- Arrhythmia and Electrophysiology, Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sergio Conti
- Department of Cardiac Electrophysiology, ARNAS Ospedali Civico Di Cristina Benfratelli, Palermo, Italy
| | - Valentina Ribatti
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgery and Dentist Sciences, University of Milan, Milan, Italy
| | - Pedro Brugada
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Josep Brugada
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Claudio Tondo
- Department of Clinical Electrophysiology & Cardiac Pacing, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgery and Dentist Sciences, University of Milan, Milan, Italy
| | - Peter J Schwartz
- Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Michel Haissaguerre
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, L’Institut de Rythmologie et modélisation Cardiaque (LIRYC), Université Bordeaux, Bordeaux, France
| | - Angelo Auricchio
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete 48, CH-6900 Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, via la Santa 1, 6962 Lugano, Switzerland
| | - Giulio Conte
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete 48, CH-6900 Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, via la Santa 1, 6962 Lugano, Switzerland
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García-Izquierdo E, Scrocco C, Palacios-Rubio J, Assaf A, Ripoll-Vera T, Hernandez-Betancor I, Ramos-Ruiz P, Melero-Pita A, Segura-Domínguez M, Jiménez-Sánchez D, Castro-Urda V, Toquero-Ramos J, Yap SC, Behr ER, Fernández-Lozano I. Arrhythmia detection using an implantable loop recorder after a negative electrophysiology study in Brugada syndrome: Observations from a multicenter international registry. Heart Rhythm 2024:S1547-5271(24)00238-8. [PMID: 38458509 DOI: 10.1016/j.hrthm.2024.03.003] [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: 02/12/2024] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Risk stratification in Brugada syndrome (BrS) remains controversial. In this respect, the role of the electrophysiology study (EPS) has been a subject of debate. In some centers, it is common practice to use an implantable loop recorder (ILR) after a negative EPS to help in risk stratification. However, the diagnostic value of this approach has never been specifically addressed. OBJECTIVE The aim of this study was to describe the baseline characteristics and the main findings of a diagnostic workup strategy with an ILR after a negative EPS in BrS. METHODS We conducted a retrospective international registry including patients with BrS and negative EPS (ie, noninducible ventricular tachycardia or ventricular fibrillation) before ILR monitoring. RESULTS The study included 65 patients from 8 referral hospitals in The Netherlands, Spain, and the United Kingdom (mean age, 39 ± 16 years; 72% male). The main indication for ILR monitoring was unexplained syncope/presyncope (66.2%). During a median follow-up of 39.0 months (Q1 25.0-Q3 47.6 months), 18 patients (27.7%) experienced 21 arrhythmic events (AEs). None of the patients died during follow-up. Bradyarrhythmias were the most common finding (47.6%), followed by atrial tachyarrhythmias (38.1%). Only 3 patients presented with ventricular arrhythmias. AEs were considered incidental in 12 patients (66.7%). In 11 patients (61.1%), AEs led to specific changes in treatment. CONCLUSION The use of ILR after a negative EPS in BrS is a safe strategy that reflected the high negative predictive value of EPS for ventricular arrhythmia in this syndrome. In addition, it allowed the detection of AEs in a significant proportion of patients, with therapeutic implications in most of them.
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Affiliation(s)
- Eusebio García-Izquierdo
- Arrhythmia Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain.
| | - Chiara Scrocco
- Cardiovascular Clinical and Genomics Research Institute, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Amira Assaf
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Tomás Ripoll-Vera
- Hospital Universitario Son Llatzer, IdISBa, Palma de Mallorca, Spain
| | | | - Pablo Ramos-Ruiz
- Department of Cardiology, University Hospital Santa Lucía, Cartagena, Spain
| | | | - Melodie Segura-Domínguez
- Arrhythmia Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Diego Jiménez-Sánchez
- Arrhythmia Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Victor Castro-Urda
- Arrhythmia Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Jorge Toquero-Ramos
- Arrhythmia Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Sing-Chien Yap
- Department of Cardiology, Thorax Center, Cardiovascular Institute, Erasmus MC, Rotterdam, The Netherlands
| | - Elijah R Behr
- Cardiovascular Clinical and Genomics Research Institute, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Ignacio Fernández-Lozano
- Arrhythmia Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
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Occhetta E, De Vecchi F, Barbonaglia L, Devecchi C, Matta M, Malacrida M, Patti G, Rametta F. Can specific ECG markers identify a pharmacologically induced type 1 Brugada pattern? Insights from a large, single-center cohort. J Electrocardiol 2023; 81:123-131. [PMID: 37688842 DOI: 10.1016/j.jelectrocard.2023.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/16/2023] [Accepted: 08/28/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND In patients with a type 2 or 3 Brugada pattern, the pharmacological (IC drugs) induction of a type 1 pattern confirms the diagnosis of Brugada syndrome. OBJECTIVE To evaluate the value of various ECG markers in predicting IC drug test results. METHODS We retrospectively analysed 443 consecutive patients referred to our Center (from January 2010 to December 2019) to undergo Ajmaline/Flecainide testing; all had a type 2 or 3 Brugada pattern or were relatives with Brugada syndrome. Clinical parameters and ECG markers (r1V1 and SV6 duration and amplitude, QRSV1/QRSV6 duration, V1 and V2 ST amplitude) were independently evaluated for their association to pharmacological test positivity, and a logistic regression model was applied. RESULTS The drug test was positive in 151 (34%) patients. On multivariate logistic regression analysis, age > 45 years, female gender, HR >60 bpm, QRSV1/QRSV6 duration >1 and non-isoelectric pattern in V2 were associated with a positive test. The percentage of patients who tested positive increased according to the presence of the above ECG markers (from 11.3% in the absence to 57.6% in the presence of both factors). During long-term follow-up, the clinical event rate was higher in patients with predictive ECG markers and very low in those without. CONCLUSIONS In our population we confirmed the ability of QRSV1/QRSV6 duration >1 and of a non-isoelectric pattern in V2 to predict a pharmacologically induced type 1 Brugada pattern. Patients with neither of these ECG markers had a rather low event rate during follow-up.
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Affiliation(s)
| | - Federica De Vecchi
- Cardiology Division, Ospedale S. Andrea, Vercelli, Italy; University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | | | - Chiara Devecchi
- Cardiology Division, Ospedale S. Andrea, Vercelli, Italy; University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Mario Matta
- Cardiology Division, Ospedale S. Andrea, Vercelli, Italy; Cardiology Division, University of Turin, Turin, Italy
| | | | - Giuseppe Patti
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
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Gaita F, Cerrato N, Saglietto A, Caponi D, Calò L, Giustetto C. The Brugada syndrome: risk stratification. Eur Heart J Suppl 2023; 25:C27-C31. [PMID: 37125275 PMCID: PMC10132603 DOI: 10.1093/eurheartjsupp/suad035] [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
Thirty years after its first description, the knowledge regarding Brugada syndrome has greatly increased. Spontaneous type 1 ECG pattern (BrECG) is a well-defined prognostic marker in asymptomatic patients and is associated with a double risk of arrhythmic events during follow-up as compared to drug-induced ECG pattern. Due to the extreme variability of the ECG pattern over time, the spontaneous type 1 BrECG must be carefully sought, not only through periodic ECGs but especially with repeated 12-lead 24-h Holter monitoring, with V1 and V2 electrodes placed also on the second and third intercostal space, in order to explore the right ventricular outflow tract. 12-lead 24-h Holter should also be performed in all the patients with a dubious BrECG pattern even before the drug challenge with sodium channel blockers, which carries a low but definite risk of complications. In addition to spontaneous type 1, other electrocardiographic markers of increased arrhythmic risk have been described, such as first-degree AV block, QRS fragmentation, S wave in lead I and II, and increased QRS duration. The electrophysiological study in asymptomatic patients with a spontaneous ECG Brugada pattern is still under jury and further studies need to clarify its precise role.
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Affiliation(s)
- Fiorenzo Gaita
- Corresponding author. Tel: +39 3357 462350, Fax: +39 0141 486132,
| | - Natascia Cerrato
- Division of Cardiology, Cardinal G. Massaia Hospital, 14100 Asti, Italy
| | - Andrea Saglietto
- Department of Medical Sciences, University of Turin, Corso Achille Mario Dogliotti 14, 10126 Turin, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, 10126 Turin, Italy
| | - Domenico Caponi
- Division of Cardiology, Cardinal G. Massaia Hospital, 14100 Asti, Italy
| | - Leonardo Calò
- Division of Cardiology, Policlinico Casilino, 00169 Rome, Italy
| | - Carla Giustetto
- Department of Medical Sciences, University of Turin, Corso Achille Mario Dogliotti 14, 10126 Turin, Italy
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Città della Salute e della Scienza’ Hospital, 10126 Turin, Italy
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Grossi S, Bianchi F, Pintor C, Musumeci G, Gaita F. Transcatheter ablation in patients with Brugada syndrome. Eur Heart J Suppl 2023; 25:C38-C43. [PMID: 37125303 PMCID: PMC10132615 DOI: 10.1093/eurheartjsupp/suad005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Since the first description of Brugada syndrome (BrS), several studies were carried out aimed at diagnosis, arrhythmic risk stratification, and available strategies for sudden death prevention. In high-risk patients, the use of an implantable cardiac defibrillator was an evident option since the first description of the syndrome. Nevertheless, this strategy, while proven, as expected, to be effective in sudden death prevention, does not prevent arrhythmias and may not be an adequate or accepted solution for all patients. The need of a non-pharmacological therapy as a potential solution based on the electrophysiological mechanisms underlying the syndrome, led to search for substrate as target for catheter ablation. Advances in the tools, technology, and technical approach enabled to launch studies aimed at mapping the epicardium of patients with BrS in order to identify and ablate the substrate. As described in previous work and in our experience, an anatomically identifiable electrical substrate, which correspond to the typical ECG, is the ablation target. Complete substrate is better identified in a larger area with sodium-channel-blockers. Ablation of all abnormal electrical potentials is able to normalize the ECG and prevent arrhythmias induction. Encouraging preliminary data, if confirmed by longer follow-up and by multicentre randomized study, could change the whole therapeutic management in BrS patients.
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Affiliation(s)
- Stefano Grossi
- Corresponding author. Tel: +390115082368, Fax: +390115082209,
| | - Francesca Bianchi
- Department of Cardiology, AO Ordine Mauriziano, Largo Turati 62, Turin 10128, Italy
| | - Chiara Pintor
- Johnson & Johnson MedTech, Biosense Webster, Via del mare 56, 00071 Pomezia (Rome), Italy
| | - Giuseppe Musumeci
- Department of Cardiology, AO Ordine Mauriziano, Largo Turati 62, Turin 10128, Italy
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Assaf A, Theuns DA, Michels M, Roos-Hesselink J, Szili-Torok T, Yap SC. Usefulness of insertable cardiac monitors for risk stratification: current indications and clinical evidence. Expert Rev Med Devices 2023; 20:85-97. [PMID: 36695092 DOI: 10.1080/17434440.2023.2171862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The 2018 ESC Syncope guidelines expanded the indications for an insertable cardiac monitor (ICM) to patients with unexplained syncope and primary cardiomyopathy or inheritable arrhythmogenic disorders. AREAS COVERED This review article discusses the clinical evidence for using an ICM for risk stratification in different patient populations including Brugada syndrome, long QT syndrome, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, cardiac sarcoidosis, and congenital heart disease. EXPERT OPINION Clinical data on the usefulness of ICMs in different patient populations is limited but most studies demonstrate early detection of clinically relevant arrhythmias, such as nonsustained ventricular tachycardia or atrial fibrillation. It is important to emphasize that the study populations usually comprise selected populations where conventional diagnostic methods fail to clarify the mechanism of symptoms. The effect of an ICM on prognosis by earlier detection of arrhythmias is difficult to demonstrate in populations with rare disease. Risk stratification in patients with cardiomyopathy or inheritable arrhythmogenic disorders remains a niche indication for ICMs. The most important indication for an ICM remains unexplained syncope in patients at low risk of SCD. Given the device costs and uncertain clinical value of device-detected arrhythmias, it is unclear whether it is also useful in non-syncopal patients.
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Affiliation(s)
- Amira Assaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dominic Amj Theuns
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Michelle Michels
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jolien Roos-Hesselink
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Tamas Szili-Torok
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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9
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Comparing the performance of published risk scores in Brugada syndrome: a multi-center cohort study. Curr Probl Cardiol 2022; 47:101381. [PMID: 36058344 DOI: 10.1016/j.cpcardiol.2022.101381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The management of Brugada Syndrome (BrS) patients at intermediate risk of arrhythmic events remains controversial. The present study evaluated the predictive performance of different risk scores in an Asian BrS population and its intermediate risk subgroup. METHODS This retrospective cohort study included consecutive patients diagnosed with BrS from January 1st, 1997 to June 20th, 2020 from Hong Kong. The primary outcome is sustained ventricular tachyarrhythmias. Two novel risk risk scores and seven machine learning-based models (random survival forest, Ada boost classifier, Gaussian naïve Bayes, light gradient boosting machine, random forest classifier, gradient boosting classifier and decision tree classifier) were developed. The area under the receiver operator characteristic (ROC) curve (AUC) [95% confidence intervals] was compared between the different models. RESULTS This study included 548 consecutive BrS patients (7% female, age at diagnosis: 50±16 years, follow-up: 84±55 months). For the whole cohort, the score developed by Sieira et al. showed the best performance (AUC: 0.806 [0.747-0.865]). A novel risk score was developed using the Sieira score and additional variables significant on univariable Cox regression (AUC: 0.855 [0.808-0.901]). A simpler score based on non-invasive results only showed a statistically comparable AUC (0.784 [0.724-0.845]), improved using random survival forests (AUC: 0.942 [0.913-0.964]). For the intermediate risk subgroup (N=274), a gradient boosting classifier model showed the best performance (AUC: 0.814 [0.791-0.832]). CONCLUSION A simple risk score based on clinical and electrocardiographic variables showed a good performance for predicting VT/VF, improved using machine learning. Abstract: The management of Brugada Syndrome (BrS) patients at intermediate risk of arrhythmic events remains controversial. This study evaluated the predictive performance of published risk scores in a cohort of BrS patients from Hong Kong (N=548) and its intermediate risk subgroup (N=274). A novel risk score developed by modifying the best performing existing score (by. Sieira et al.) showed an area under the curve of 0.855 and 0.760 for the whole BrS cohort and the intermediate risk subgroup, respectively. The performance of the different scores was significantly improved machine learning-based methods, such as random survival forests and gradient boosting classifier.
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10
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Balfe C, Durand R, Crinion D, Ward D, Sheahan R. The evidence for the implantable loop recorder in patients with inherited arrhythmia syndromes: a review of the literature. Europace 2021; 24:706-712. [PMID: 34791164 DOI: 10.1093/europace/euab256] [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: 06/20/2021] [Accepted: 09/26/2021] [Indexed: 11/12/2022] Open
Abstract
Risk stratification of patients with inherited arrhythmia syndromes (IASs) can be challenging. Recent guidelines acknowledge a place for considering the implantable loop recorder (ILR) to outrule malignant arrhythmia as a cause of syncope in certain inherited arrhythmia patients who are at low risk of sudden cardiac death. In this comprehensive literature review, we evaluate the available evidence for the use of the ILR in the IASs and in relatives of victims of sudden arrhythmic death syndrome.
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Affiliation(s)
- Christopher Balfe
- Cardiology Department, Beaumont Hospital, Beaumont Road, Beaumont, Ireland
| | - Rory Durand
- Centre for Cardiac Risk in the Young Persons (CRYP), Tallaght University Hospital, Tallaght, Co. Dublin, Ireland
| | - Derek Crinion
- Centre for Cardiac Risk in the Young Persons (CRYP), Tallaght University Hospital, Tallaght, Co. Dublin, Ireland
| | - Deirdre Ward
- Centre for Cardiac Risk in the Young Persons (CRYP), Tallaght University Hospital, Tallaght, Co. Dublin, Ireland
| | - Richard Sheahan
- Cardiology Department, Beaumont Hospital and Royal College of Surgeons in Ireland, Beaumont, Co. Dublin, Ireland
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11
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Scrocco C, Ben-Haim Y, Devine B, Tome-Esteban M, Papadakis M, Sharma S, Macfarlane PW, Behr ER. Role of subcutaneous implantable loop recorder for the diagnosis of arrhythmias in Brugada syndrome: A United Kingdom single-center experience. Heart Rhythm 2021; 19:70-78. [PMID: 34487893 DOI: 10.1016/j.hrthm.2021.08.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 08/09/2021] [Accepted: 08/22/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Experience with implantable loop recorders (ILRs) in Brugada syndrome (BrS) is limited. OBJECTIVE The purpose of this study was to evaluate the indications and yield of ILR monitoring in a single-center BrS registry. METHODS Demographic, clinical and follow-up data of BrS patients with ILR were collected. RESULTS Of 415 BrS patients recruited consecutively, 50 (12%) received an ILR (58% male). Mean age at ILR implantation was 44 ± 15 years. Thirty-one (62%) had experienced syncopal or presyncopal episodes, and 23 (46%) had palpitations. During median follow-up of 28 months (range 1-68), actionable events were detected in 11 subjects (22%); 7 had recurrences of syncope/presyncope, with 4 showing defects in sinus node function or atrioventricular conduction. New supraventricular tachyarrhythmias were recorded in 6 subjects; a run of fast nonsustained ventricular tachycardia was detected in 1 patient. Patients implanted with an ILR were less likely to show a spontaneous type 1 pattern or depolarization electrocardiographic (ECG) abnormalities compared to those receiving a primary prevention implantable-cardioverter defibrillator. Age at implantation, gender, Shanghai score, and ECG parameters did not differ between subjects with and those without actionable events. ILR-related complications occurred in 3 cases (6%). CONCLUSION In a large cohort of BrS patients, continuous ILR monitoring yielded a diagnosis of tachy- or bradyarrhythmic episodes in 22% of cases. Recurrences of syncope were associated with bradyarrhythmic events. Use of ILR can be helpful in guiding the management of low-/intermediate-risk BrS patients and ascertaining the cause of unexplained syncope.
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Affiliation(s)
- Chiara Scrocco
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Yael Ben-Haim
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Brian Devine
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Maite Tome-Esteban
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Michael Papadakis
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sanjay Sharma
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Peter W Macfarlane
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Elijah R Behr
- Cardiovascular Clinical Academic Group St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom.
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12
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Mascia G, Bona RD, Ameri P, Canepa M, Porto I, Parati G, Crotti L, Brignole M. Brugada syndrome and syncope: a practical approach for diagnosis and treatment. Europace 2021; 23:996-1002. [PMID: 33367713 DOI: 10.1093/europace/euaa370] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/17/2020] [Indexed: 11/13/2022] Open
Abstract
Syncope in patients with Brugada electrocardiogram pattern may represent a conundrum in the decision algorithm because incidental benign forms, especially neurally mediated syncope, are very frequent in this syndrome similarly to the general population. Arrhythmic syncope in Brugada syndrome typically results from a self-terminating sustained ventricular tachycardia or paroxysmal ventricular fibrillation, potentially leading to sudden cardiac death. Distinguishing syncope due to malignant arrhythmias from a benign form is often difficult unless an electrocardiogram is recorded during the episode. We performed a review of the existing literature and propose a practical approach for diagnosis and treatment of the patients with Brugada syndrome and syncope.
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Affiliation(s)
- Giuseppe Mascia
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Roberta Della Bona
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Marco Canepa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Italo Porto
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Lia Crotti
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Center for Cardiac Arrhythmias of Genetic Origin, Milan, Italy
| | - Michele Brignole
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy.,Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Faint & Fall Programme, Ospedale San Luca, Piazzale Brescia 20, 20149 Milan, Italy.,Department of Cardiology, Arrhythmologic Centre, Ospedali del Tigullio, Lavagna, Italy
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13
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Mascia G, Della Bona R, Ameri P, Canepa M, Porto I, Brignole M. Brugada syndrome and syncope: A systematic review. J Cardiovasc Electrophysiol 2020; 31:3334-3338. [PMID: 33090608 DOI: 10.1111/jce.14787] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 09/25/2020] [Accepted: 10/05/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Distinguishing syncope due to malignant arrhythmias from an incidental benign form in Brugada syndrome (BrS) is often difficult. Through systematic literature review, we evaluated the role of syncope in predicting subsequent malignant arrhythmias in BrS. METHODS A comprehensive literature search was performed on PubMed (MeSH search terms "Brugada syndrome" and "syncope"). Overall, 9 studies for a total of 1347 patients were included. Patients were stratified as affected by suspected arrhythmic syncope (SAS), undefined syncope (US) or neurally-mediated syncope (NMS). RESULTS Overall, 15.7% of the 279 patients with SAS had malignant arrhythmic events during a mean follow-up of 67 months, corresponding to 2.8 events per 100/person year. At the same time, 7% of the 527 patients affected by US had malignant arrhythmias during a mean follow-up of 39 months, corresponding 2.2 events per 100/person year. Conversely, 0.7% of 541 patients with NMS had malignant arrhythmic events at follow-up, corresponding to 0.13 events per 100/person year (p = .0001 NMS versus SAS and US pooled). CONCLUSION In BrS population, the risk of arrhythmic events in the follow-up may be stratified according to the clinical evaluation. The "relatively" low predictive value of the clinical diagnosis of SAS warrants for a more accurate multi-parametric assessment, to restrict the number of candidates for implantable cardioverter-defibrillator therapy.
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Affiliation(s)
- Giuseppe Mascia
- CardioThoracoVascular Department, Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Roberta Della Bona
- CardioThoracoVascular Department, Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Pietro Ameri
- CardioThoracoVascular Department, Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Marco Canepa
- CardioThoracoVascular Department, Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Italo Porto
- CardioThoracoVascular Department, Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Michele Brignole
- Faint and Fall Program, Ospedale San Luca, IRCCS Istituto Auxologico Italiano, Milan, Italy
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14
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Lee S, Zhou J, Liu T, Letsas KP, Hothi SS, Vassiliou VS, Li G, Baranchuk A, Sy RW, Chang D, Zhang Q, Tse G. Temporal Variability in Electrocardiographic Indices in Subjects With Brugada Patterns. Front Physiol 2020; 11:953. [PMID: 33013434 PMCID: PMC7494959 DOI: 10.3389/fphys.2020.00953] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/15/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction Patients with Brugada electrocardiographic (ECG) patterns have differing levels of arrhythmic risk. We hypothesized that temporal variations in certain ECG markers may provide additional value for risk stratification. The present study evaluated the relationship between temporal variability of ECG markers and arrhythmic outcomes in patients with a Brugada pattern ECG. Comparisons were made between low-risk asymptomatic subjects versus high-risk symptomatic patients with a history of syncope, ventricular tachycardia (VT) or ventricular fibrillation (VF). Methods A total of 81 patients presenting with Brugada patterns were recruited. Serial ECGs and electronic health records from January 2004 to April 2019 were analyzed. Temporal variability of QRS interval, J point-Tpeak interval (JTp), Tpeak-Tend interval (Tp-e), and ST elevation (STe) in precordial leads V1-3, in addition to RR-interval from lead II, was assessed using standard deviation and difference between maximum and minimum values over the serial ECGs. Results Patients presenting with type 1 Brugada ECG pattern initially had significantly higher variability in JTp from lead V2 (SD: 33.5 ± 13.8 vs. 25.2 ± 11.5 ms, P = 0.009; max-min: 98.6 ± 46.2 vs. 78.3 ± 47.6 ms, P = 0.047) and ST elevation in lead V1 (0.117 ± 0.122 vs. 0.053 ± 0.030 mV; P = 0.004). Significantly higher variability in Tp-e interval measured from lead V3 was observed in the VT/VF group compared to the syncope and asymptomatic groups (SD: 20.5 ± 8.5 vs. 16.6 ± 7.3 and 14.7 ± 9.8 ms; P = 0.044; max-min: 70.2 ± 28.9 vs. 56.3 ± 29.0 and 43.5 ± 28.5 ms; P = 0.011). Conclusion Temporal variability in ECG indices may provide additional value for risk stratification in patients with Brugada pattern.
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Affiliation(s)
- Sharen Lee
- Laboratory of Cardiovascular Physiology, Li Ka Shing Institute of Health Sciences, Hong Kong, China
| | - Jiandong Zhou
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - 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
| | - Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Sandeep S Hothi
- Heart and Lung Centre, New Cross Hospital, Wolverhampton, United Kingdom
| | - Vassilios S Vassiliou
- Norwich Medical School, University of East Anglia, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Guoliang Li
- Arrhythmia Unit, Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - Raymond W Sy
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Dong Chang
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
| | - Qingpeng Zhang
- School of Data Science, City University of Hong Kong, Hong Kong, China
| | - Gary Tse
- 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.,Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
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15
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[Syncope]. Internist (Berl) 2020; 61:813-826. [PMID: 32542492 DOI: 10.1007/s00108-020-00821-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Syncope is a frequent disorder, sometimes due to life-threatening causes. The uncertainty in its diagnosis requires a standardized approach. According to the 2018 European Society of Cardiology (ESC) guidelines, new aspects in evaluation and treatment include risk stratification and decision-making strategies during the initial evaluation in the emergency department, a reconsideration of diagnostic tests, algorithms for the treatment of reflex syncope, indications for an implantable cardioverter/defibrillator in high risk patients for sudden cardiac death, and organizational aspects such as interdisciplinary syncope units. The 2018 ESC guideline and the 2019 commentaries of the German Society of Cardiology (DGK) are an excellent and comprehensive instruction for safe, effective and efficient evaluation and therapy. However, some aspects require critical appraisal. The inadequate availability and reimbursement of pivotal diagnostic tests, such as tilt table testing and the implantable loop recorder is emphasized.
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16
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Sakhi R, Assaf A, Theuns DAMJ, Verhagen JMA, Szili-Torok T, Roos-Hesselink JW, Yap SC. Outcome of Insertable Cardiac Monitors in Symptomatic Patients with Brugada Syndrome at Low Risk of Sudden Cardiac Death. Cardiology 2020; 145:413-420. [PMID: 32320984 DOI: 10.1159/000507075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/06/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION There is limited data on the experience with insertable cardiac monitors (ICMs) in patients with Brugada syndrome. OBJECTIVE To evaluate the outcome of ICM in symptomatic patients with Brugada syndrome who are at suspected low risk of sudden cardiac death (SCD). METHODS We conducted a prospective single-center cohort study including all symptomatic patients with Brugada syndrome who received an ICM (Reveal LINQ) between July 2014 and October 2019. The main indication for monitoring was to exclude ventricular arrhythmias as the cause of symptoms and to establish a symptom-rhythm relationship. RESULTS A total of 20 patients (mean age, 39 ± 12 years; 55% male) received an ICM during the study period. Nine patients (45%) had a history of syncope (presumed nonarrhythmogenic), and 5 patients had a recent syncope (<6 months). During a median follow-up of 32 months (interquartile range, 11-36 months), 3 patients (15%) experienced an episode of nonsustained ventricular arrhythmia. No patient died suddenly or experienced a sustained ventricular arrhythmia, and no patient had a recurrence of syncope. Overall, 17 patients (85%) experienced symptoms during follow-up, of whom 10 patients had an ICM-detected arrhythmia. In 4 patients (20%), the ICM-detected arrhythmia was an actionable event. ICM-guided management included antiarrhythmic drug therapy for symptomatic ectopic beats (n = 3), pulmonary vein isolation, and oral anticoagulation for atrial fibrillation (n = 1), electrophysiological study for risk stratification (n = 1), and pacemaker implantation for atrioventricular block (n = 1). CONCLUSIONS An ICM can be used to exclude ventricular arrhythmias in symptomatic patients with Brugada syndrome at low risk of SCD. Furthermore, an ICM-detected arrhythmia changed clinical management in 20% of patients.
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Affiliation(s)
- Rafi Sakhi
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Amira Assaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dominic A M J Theuns
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Judith M A Verhagen
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tamas Szili-Torok
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jolien W Roos-Hesselink
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands,
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17
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Hernandez-Ojeda J, Arbelo E, Jorda P, Borras R, Campuzano O, Sarquella-Brugada G, Iglesias A, Mont L, Brugada R, Brugada J. The role of clinical assessment and electrophysiology study in Brugada syndrome patients with syncope. Am Heart J 2020; 220:213-223. [PMID: 31864099 DOI: 10.1016/j.ahj.2019.10.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 10/12/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cardiogenic syncope in Brugada syndrome (BrS) increases the risk of major events. Nevertheless, clinical differentiation between cardiogenic and vasovagal syncope can be challenging. We characterized the long-term incidence of major events in a large cohort of BrS patients who presented with syncope. METHODS From a total of 474 patients, syncope was the initial manifestation in 135 (28.5%) individuals (43.9 ± 13.9 years, 71.1% male). The syncope was classified prospectively as cardiogenic, vasovagal, or undefined if unclear characteristics were present. Clinical, electrocardiographic, genetic, and electrophysiologic features were analyzed. Cardiogenic syncope, sustained ventricular arrhythmias, and sudden death were considered major events in follow-up. RESULTS In 66 patients (48.9%), the syncope was cardiogenic; in 51 (37.8%), vasovagal and in 18 (13.3%); undefined. The electrophysiology study (EPS) inducibility was more frequent in patients with cardiogenic syncope and absent in all patients with undefined syncope (28 [53.8%] vs 5 [12.2%] vs 0 [0%]; P < .01). During follow-up (7.7 ± 5.6 years), only patients with cardiogenic syncope presented major events (16 [11.9%]). Among patients with inducible EPS, 7 (21.2%) presented major events (P = .04). The negative predictive value of the EPS for major events was 92.4%. The incidence rate of major events was 2.6% person-year. Parameters associated with major events included cardiogenic syncope (hazard ratio [HR] 6.3; 95% CI 1.1-10.4; P = .05), spontaneous type 1 electrocardiogram (HR 3.7; 95% CI 1.3-10.5; P = .01), and inducible EPS (HR 2.8; 95% CI 1.1-8.8; P = .05). CONCLUSIONS An accurate syncope classification is crucial in BrS patients for risk stratification. In patients with syncope of unclear characteristics, the EPS may be helpful to prevent unnecessary implantable cardioverter defibrillators.
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Affiliation(s)
- Jaime Hernandez-Ojeda
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona. Barcelona, Spain; IDIBAPS, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona. Barcelona, Spain; IDIBAPS, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Paloma Jorda
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona. Barcelona, Spain; IDIBAPS, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Roger Borras
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona. Barcelona, Spain; IDIBAPS, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Oscar Campuzano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Cardiovascular Genetics Center, University of Girona-IDIBGI, Girona, Spain; Medical Science Department, School of Medicine, University of Girona, Girona, Spain
| | - Georgia Sarquella-Brugada
- Medical Science Department, School of Medicine, University of Girona, Girona, Spain; Arrhythmia Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Anna Iglesias
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Cardiovascular Genetics Center, University of Girona-IDIBGI, Girona, Spain; Medical Science Department, School of Medicine, University of Girona, Girona, Spain
| | - Lluis Mont
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona. Barcelona, Spain; IDIBAPS, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ramon Brugada
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Cardiovascular Genetics Center, University of Girona-IDIBGI, Girona, Spain; Medical Science Department, School of Medicine, University of Girona, Girona, Spain; Cardiology Service, Hospital Josep Trueta, Girona, Spain
| | - Josep Brugada
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona. Barcelona, Spain; IDIBAPS, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Arrhythmia Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
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18
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Giustetto C, Nangeroni G, Cerrato N, Rudic B, Tülümen E, Gribaudo E, Giachino DF, Barbonaglia L, Biava LM, Carvalho P, Bergamasco L, Borggrefe M, Gaita F. Ventricular conduction delay as marker of risk in Brugada Syndrome. Results from the analysis of clinical and electrocardiographic features of a large cohort of patients. Int J Cardiol 2019; 302:171-177. [PMID: 31771792 DOI: 10.1016/j.ijcard.2019.11.121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/04/2019] [Accepted: 11/15/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND Brugada Syndrome is a genetic arrhythmogenic disease with a variable clinical spectrum. The role of clinical and ECG parameters in the risk stratification is still uncertain. AIMS In a large cohort of Brugada patients we analysed clinical and ECG features to determine the variables with prognostic value for the occurrence of a first documented arrhythmic event and for recurrences. METHODS We enrolled 614 patients, subdivided into 3 groups according to their clinical presentation: 531 (88%) asymptomatic, 69 (10%) with previous unexplained syncope and 14 (2%) with aborted sudden death. We also compared the ECG characteristics of patients with a single documented arrhythmic event (either at presentation or at follow-up, 17 patients), with those of patients with arrhythmic recurrences (13 patients). RESULTS The event rate was 1.3% in the asymptomatic patients and 15% among patients with unexplained syncope (median follow-up 6 years), p < 0.0001. In both groups a QRS duration ≥110 ms in lead II and/or V6 and/or S wave duration ≥40 ms in lead I and/or II were significant risk factors for the occurrence and timing of events at follow-up. The same ECG risk factors were also significantly associated with arrhythmic recurrences. CONCLUSIONS The arrhythmic risk of Brugada patients is related not only to the symptoms at presentation, but also to the presence of a ventricular conduction delay (QRS duration ≥ 110 ms and/or S wave duration ≥ 40 ms). The ECG conduction parameters also affect the timing of events and recurrences.
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Affiliation(s)
- Carla Giustetto
- Division of Cardiology, University of Torino, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Torino, Italy.
| | - Giulia Nangeroni
- Division of Cardiology, University of Torino, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Torino, Italy
| | - Natascia Cerrato
- Division of Cardiology, University of Torino, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Torino, Italy
| | - Boris Rudic
- 1st Department of Medicine-Cardiology, University Medical Center Mannheim, Mannheim, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Erol Tülümen
- 1st Department of Medicine-Cardiology, University Medical Center Mannheim, Mannheim, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Elena Gribaudo
- Division of Cardiology, University of Torino, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Torino, Italy
| | - Daniela Francesca Giachino
- Medical Genetics, University of Torino, Department of Clinical and Biological Sciences, San Luigi Gonzaga Hospital, Orbassano, Italy
| | | | - Lorenza Michela Biava
- Division of Cardiology, University of Torino, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Torino, Italy
| | - Paula Carvalho
- Division of Cardiology, University of Torino, San Luigi Gonzaga Hospital, Orbassano, Italy
| | - Laura Bergamasco
- Division of Cardiology, University of Torino, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Torino, Italy
| | - Martin Borggrefe
- 1st Department of Medicine-Cardiology, University Medical Center Mannheim, Mannheim, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Fiorenzo Gaita
- Division of Cardiology, University of Torino, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, Torino, Italy
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von Scheidt W, Bosch R, Klingenheben T, Schuchert A, Stellbrink C, Stockburger M. Manual zur Diagnostik und Therapie von Synkopen. KARDIOLOGE 2019. [DOI: 10.1007/s12181-019-0319-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sakhi R, Theuns DAMJ, Szili-Torok T, Yap SC. Insertable cardiac monitors: current indications and devices. Expert Rev Med Devices 2018; 16:45-55. [PMID: 30522350 DOI: 10.1080/17434440.2018.1557046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Recurrent unexplained syncope is a well-established indication for an insertable cardiac monitor (ICM). Recently, the indications for an ICM have been expanded. AREAS COVERED This review article discusses the current indications for ICMs and gives an overview of the latest generation of commercially available ICMs. EXPERT COMMENTARY The 2018 ESC Syncope guidelines have expanded the indications for an ICM to patients with inherited cardiomyopathy, inherited channelopathy, suspected unproven epilepsy, and unexplained falls. ICMs are also increasingly used for the detection of subclinical atrial fibrillation (AF) in patients with cryptogenic stroke. Whether treatment of subclinical AF (SCAF) with oral anticoagulation prevents recurrent stroke is yet unknown. The current generation of ICMs are smaller, easier to implant, have better diagnostics, and are capable of remote monitoring. The Reveal LINQ (Medtronic) is the smallest ICM and has the most extensive performance and clinical data. The BioMonitor 2 (Biotronik) is the largest ICM but has excellent R-wave amplitudes, longest longevity, and reliable remote monitoring. The Confirm Rx (Abbott) is capable to provide mobile data transmission enabled by a smartphone app. Future generation of ICMs will incorporate heart failures indices to facilitate remote monitoring of heart failure patients.
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Affiliation(s)
- Rafi Sakhi
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Dominic A M J Theuns
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Tamas Szili-Torok
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Sing-Chien Yap
- a Department of Cardiology, Thoraxcenter , Erasmus Medical Center , Rotterdam , The Netherlands
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Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883-1948. [PMID: 29562304 DOI: 10.1093/eurheartj/ehy037] [Citation(s) in RCA: 927] [Impact Index Per Article: 154.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Boveda S, Laarakker MC, Cardin C, Albenque JP. Impact of a novel algorithm designed to reduce T-wave oversensing with the subcutaneous defibrillator in a patient with type I Brugada electrocardiogram. HeartRhythm Case Rep 2018; 4:31-33. [PMID: 29379724 PMCID: PMC5775447 DOI: 10.1016/j.hrcr.2017.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Serge Boveda
- Cardiac Arrhythmias Management, Cardiology Department, Clinique Pasteur, Toulouse, France
| | | | - Christèle Cardin
- Cardiac Arrhythmias Management, Cardiology Department, Clinique Pasteur, Toulouse, France
| | - Jean-Paul Albenque
- Cardiac Arrhythmias Management, Cardiology Department, Clinique Pasteur, Toulouse, France
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Belhassen B, Milman A. Syncope in Brugada syndrome: A plea for thorough anamnesis and EPS. The lessons from our journey in the region of Piedmont, Italy. Int J Cardiol 2017; 241:241-242. [DOI: 10.1016/j.ijcard.2017.03.145] [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: 03/12/2017] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 11/16/2022]
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Assessing the clinical efficacy of quinidine in Brugada syndrome: "Mission: Impossible"? Heart Rhythm 2017; 14:1155-1156. [PMID: 28455270 DOI: 10.1016/j.hrthm.2017.04.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Indexed: 12/31/2022]
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