Brugada syndrome treatment: Difference between revisions
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Administration of [[Lithium]] can result in EKG manifestations of the Brugada syndrome. <ref>Pirotte MJ, Mueller JG, Poprawski T. A case report of Brugada-type electrocardiographic changes in a patient taking lithium. Am J Emerg Med. 2008; 26: 113.</ref><ref>Wright D, Salehian O. Brugada-Type Electrocardiographic Changes Induced by Long-Term Lithium Use. Circulation, FRCPC2010;122:e418-e419</ref>. [[Syncope]] and [[sudden cardiac death]] have been observed in these patients.<ref>Laske C, Soekadar SR, Laszlo R, Plewnia C. Brugada syndrome in a patient treated with lithium. Am J Psychiatry. 2007; 164: 1440–1441. </ref> | Administration of [[Lithium]] can result in EKG manifestations of the Brugada syndrome. <ref>Pirotte MJ, Mueller JG, Poprawski T. A case report of Brugada-type electrocardiographic changes in a patient taking lithium. Am J Emerg Med. 2008; 26: 113.</ref><ref>Wright D, Salehian O. Brugada-Type Electrocardiographic Changes Induced by Long-Term Lithium Use. Circulation, FRCPC2010;122:e418-e419</ref>. [[Syncope]] and [[sudden cardiac death]] have been observed in these patients.<ref>Laske C, Soekadar SR, Laszlo R, Plewnia C. Brugada syndrome in a patient treated with lithium. Am J Psychiatry. 2007; 164: 1440–1441. </ref> | ||
The putative role of [[lithium]] has been suggested in so far as withdrawal of [[lithium]] results in either 1) normalization of the ECG or 2) conversion of the Brugada pattern to type 2 or 3. The appearance of Brugada type EKG patterns does not require toxic [[lithium]] levels. | The putative role of [[lithium]] has been suggested in so far as withdrawal of [[lithium]] results in either 1) normalization of the ECG or 2) conversion of the Brugada pattern to type 2 or 3. The appearance of Brugada type EKG patterns does not require toxic [[lithium]] levels. | ||
'''Drugs with potential antiarrhythmic effect''' | '''Drugs with potential antiarrhythmic effect''' | ||
Revision as of 15:28, 14 October 2012
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Brugada syndrome Microchapters |
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Risk calculators and risk factors for Brugada syndrome treatment |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The cause of death in Brugada syndrome is ventricular fibrillation.The episodes of syncope (fainting) and sudden death (aborted or not) are caused by fast polymorphic ventricular tachycardias or ventricular fibrillation. These arrhythmias appear with no warning. While there is no exact treatment modality that reliably and totally prevents ventricular fibrillation from occurring in this syndrome, treatment lies in termination of this lethal arrhythmia before it causes death. This is done via implantation of an implantable cardioverter-defibrillator (ICD), which continuously monitors the heart rhythm and will defibrillate an individual if ventricular fibrillation is noted. Some recently performed studies had evaluated the role of quinidine, a Class Ia antiarrythmic drug, for decreasing VF episodes occurring in this syndrome. Quinidine was found to decrease number of VF episodes and correcting spontaneous ECG changes, possibly via inhibiting Ito channels.[1] Those with risk factors for coronary artery disease may require an angiogram before ICD implantation.
- Aborted sudden death are at high risk for recurrence and should undergo AICD implantation. Patients who are symptomatic with unexplained [[syncope], ventricular tachycardia or aborted sudden cardiac death may have a symptom recurrence risk of 2% to 10% per year. In these patients an AICD implant is advisable.
- VT storm has been successfully treated with Isoproterenol. The mechanism is thought to be augmenting the cardiac L type channel.
- Asymptomatic patients require risk stratification and clinical judegement to help guide therapy
- Quinidine (class IA sodium channel blocker) blocks the Ito current and is proven to suppress spontaneous VF
- Cilostazol (phosphodiesterase III inhibitor that increases inward L type calcium channel current and reported to suppress spontaneous VF
- Bepridil suppress spontaneous VF probably through blocking Ito current
- Medical therapy alone with the above agents is currently not evaluated in randomized trials and should not be used as loan therapy.
Lithium Treatment and Brugada Syndrome
Administration of Lithium can result in EKG manifestations of the Brugada syndrome. [2][3]. Syncope and sudden cardiac death have been observed in these patients.[4] The putative role of lithium has been suggested in so far as withdrawal of lithium results in either 1) normalization of the ECG or 2) conversion of the Brugada pattern to type 2 or 3. The appearance of Brugada type EKG patterns does not require toxic lithium levels. Drugs with potential antiarrhythmic effect
(Alphabetical order generic name)
| Generic name | Brand name® | Class / Clinical use | References | Recommendation |
| Cilostazol | e.g. Pletal® |
Phosphodiesterase inhibitor | Tsuchiya 2002 Abud 2006 Matsui 1999 |
Class IIb |
| Isoproterenol Isoprenaline |
e.g. Isuprel® |
Beta-adrenergic receptor stimulation | Miyazaki 1996 Suzuki 2000 Watanabe 2006 Ohgo 2007 Ganesan 2006 |
Class I |
| Orciprenaline | e.g. Alotec® Metaprel® Novasmasol® |
Beta-adrenergic receptor stimulation | Kyriazis 2009 | Class IIa |
| Quinidine | e.g. Quinalan® Chinidin® |
Antiarrhythmic Agent | Suzuki 2000 Alings 2001 Belhassen 2004 Mizusawa 2006 Probst 2007 Ohgo 2007 Yan 1999 |
Class I |
Recommendation: Class I: convincing evidence/opinion; Class IIa: evidence/opinion less clear; Class IIb: conflicting evidence/opinion; Class III: very little evidence.
ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT) [5]
Recommendations for Brugada Syndrome
| Class I |
| "1. An ICD is indicated for Brugada syndrome patients with previous cardiac arrest receiving chronic optimal medical therapy and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: C)" |
| Class IIa |
| "1. An ICD is reasonable for Brugada syndrome patients with spontaneous ST-segment elevation in V1, V2, or V3 who have had syncope with or without mutations demonstrated in the SCN5A gene and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: C)" |
| "2. Clinical monitoring for the development of a spontaneous ST-segment elevation pattern is reasonable for the management of patients with ST-segment elevation induced only with provocative pharmacological challenge with or without symptoms. (Level of Evidence: C)" |
| "3. An ICD is reasonable for Brugada syndrome patients with documented VT that has not resulted in cardiac arrest and who have reasonable expectation of survival with a good functional status for more than 1 y. (Level of Evidence: C)" |
| "4. Isoproterenol can be useful to treat an electrical storm in the Brugada syndrome. (Level of Evidence: C)" |
| Class IIb |
| "1. EP testing may be considered for risk stratification in asymptomatic Brugada syndrome patients with spontaneous ST elevation with or without a mutation in the SCN5A gene. (Level of Evidence: C)" |
| "2. Quinidine might be reasonable for the treatment of electrical storm in patients with Brugada syndrome.(Level of Evidence: C)" |
References
- ↑ Belhassen B, Glick A, Viskin S (2004). "Efficacy of quinidine in high-risk patients with Brugada syndrome". Circulation. 110 (13): 1731–7. doi:10.1161/01.CIR.0000143159.30585.90. PMID 15381640.
- ↑ Pirotte MJ, Mueller JG, Poprawski T. A case report of Brugada-type electrocardiographic changes in a patient taking lithium. Am J Emerg Med. 2008; 26: 113.
- ↑ Wright D, Salehian O. Brugada-Type Electrocardiographic Changes Induced by Long-Term Lithium Use. Circulation, FRCPC2010;122:e418-e419
- ↑ Laske C, Soekadar SR, Laszlo R, Plewnia C. Brugada syndrome in a patient treated with lithium. Am J Psychiatry. 2007; 164: 1440–1441.
- ↑ Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M; et al. (2006). "ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (10): e385–484. doi:10.1161/CIRCULATIONAHA.106.178233. PMID 16935995.