Brugada syndrome treatment
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
Treatment
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 receive an ICD
- 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.
Sodium Challenge
- Drugs that can be used
- Ajmaline 1 mg/kg/5 min IV
- Flecainide 2 mg/kg/10 min IV or 400 mg PO
- Procainamide 10 mg/kg/10 min IV
- Pilsicainide 1 mg/kg/10 min IV
- The sodium challenge should be terminated when
- Diagnostic Type 1 ST-segment elevation or Brugada ECG, develops
- ST segment in Type 2 increases by ≥2 mm
- Premature ventricular beats or other arrhythmias develop
- QRS widens to ≥130% of baseline
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.