Brugada syndrome risk factors

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The EKG changes of Brugada syndrome can vary over time, depending on the autonomic balance and the administration of antiarrhythmic drugs. Adrenergic stimulation decreases the ST segment elevation, while vagal stimulation worsens it. During sleep, there is heightened vagal tone, and the pattern may be exacerbated at that time (as is the risk of sudden cardiac death at that time). The administration of class Ia, Ic and III drugs increases the ST segment elevation, as does fever. The impact of exercise depends upon when the EKG is obtained: during exercise the ST segment elevation may decrease but may increase later after exercise when the body temperature has risen. Similar to early repolarization variant, when the heart rate decreases, the ST segment elevation increases and when the heart rate increases the ST segment elevation decreases. While Brugada syndrome is often associated with polymorphic VT which may be self terminating, in the presence of autonomic imbalance, hypokalemia, fever or exacerbating drugs sustained ventricular fibrillation and sudden cardiac death may result.[1]

Risk Factors: Agents and Scenarios that Provoke the Brugada Syndrome Pattern

The electrocardiographic findings of Brugada syndrome are often concealed, but can be unmasked or modulated by a number of drugs and pathophysiological states including (in alphabetical order)[1]:

Risk Statification[33][34]

  • Patients with syncope and an abnormal Type 1 ECG are at higher risk
  • Asymptomatic patients at risk can be identified
    • Presence of spontaneous Type 1 ST-segment elevation
    • Characteristics of the S wave
    • Presence of late potentials
    • Inducibility of VT/VF using PES is controversial as a risk factor. Some groups have advocated that programmed electrical stimulation (PES) be performed to induce ventricular fibrillation for risk assessment in Brugada patients [35][36]

Other groups have not reproduced the predictive value of these tests,[33][37] so the value of programmed electrical stimulation (PES) and inducibility remains controversial.

References

  1. ↑ 1.0 1.1 1.2 Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, Gussak I, LeMarec H, Nademanee K, Perez Riera AR, Shimizu W, Schulze-Bahr E, Tan H, Wilde A (2005). "Brugada syndrome: report of the second consensus conference". Heart Rhythm : the Official Journal of the Heart Rhythm Society. 2 (4): 429–40. PMID 15898165. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  2. ↑ Nogami A, Nakao M, Kubota S, Sugiyasu A, Doi H, Yokoyama K; et al. (2003). "Enhancement of J-ST-segment elevation by the glucose and insulin test in Brugada syndrome". Pacing Clin Electrophysiol. 26 (1 Pt 2): 332–7. PMID 12687840.
  3. ↑ Rolf S, Bruns HJ, Wichter T, Kirchhof P, Ribbing M, Wasmer K; et al. (2003). "The ajmaline challenge in Brugada syndrome: diagnostic impact, safety, and recommended protocol". Eur Heart J. 24 (12): 1104–12. PMID 12804924.
  4. ↑ 4.0 4.1 4.2 Miyazaki T, Mitamura H, Miyoshi S, Soejima K, Aizawa Y, Ogawa S (1996). "Autonomic and antiarrhythmic drug modulation of ST segment elevation in patients with Brugada syndrome". J Am Coll Cardiol. 27 (5): 1061–70. doi:10.1016/0735-1097(95)00613-3. PMID 8609322.
  5. ↑ 5.0 5.1 5.2 5.3 Brugada P, Brugada J, Brugada R (2000). "Arrhythmia induction by antiarrhythmic drugs". Pacing Clin Electrophysiol. 23 (3): 291–2. PMID 10750126.
  6. ↑ Ortega-Carnicer J, Bertos-Polo J, Gutiérrez-Tirado C (2001). "Aborted sudden death, transient Brugada pattern, and wide QRS dysrrhythmias after massive cocaine ingestion". J Electrocardiol. 34 (4): 345–9. PMID 11590577.
  7. ↑ 7.0 7.1 Rouleau F, Asfar P, Boulet S, Dube L, Dupuis JM, Alquier P; et al. (2001). "Transient ST segment elevation in right precordial leads induced by psychotropic drugs: relationship to the Brugada syndrome". J Cardiovasc Electrophysiol. 12 (1): 61–5. PMID 11204086.
  8. ↑ Antzelevitch C, Brugada R (2002). "Fever and Brugada syndrome". Pacing Clin Electrophysiol. 25 (11): 1537–9. PMID 12494608.
  9. ↑ González Rebollo JM, Hernández Madrid A, García A, García de Castro A, Mejías A, Moro C (2000). "[Recurrent ventricular fibrillation during a febrile illness in a patient with the Brugada syndrome]". Rev Esp Cardiol. 53 (5): 755–7. PMID 10816181.
  10. ↑ Saura D, García-Alberola A, Carrillo P, Pascual D, Martínez-Sánchez J, Valdés M (2002). "Brugada-like electrocardiographic pattern induced by fever". Pacing Clin Electrophysiol. 25 (5): 856–9. PMID 12049381.
  11. ↑ Porres JM, Brugada J, Urbistondo V, García F, Reviejo K, Marco P (2002). "Fever unmasking the Brugada syndrome". Pacing Clin Electrophysiol. 25 (11): 1646–8. PMID 12494626.
  12. ↑ Kum LC, Fung JW, Sanderson JE (2002). "Brugada syndrome unmasked by febrile illness". Pacing Clin Electrophysiol. 25 (11): 1660–1. PMID 12494630.
  13. ↑ Fujiki A, Usui M, Nagasawa H, Mizumaki K, Hayashi H, Inoue H (1999). "ST segment elevation in the right precordial leads induced with class IC antiarrhythmic drugs: insight into the mechanism of Brugada syndrome". J Cardiovasc Electrophysiol. 10 (2): 214–8. PMID 10090224.
  14. ↑ 14.0 14.1 Krishnan SC, Josephson ME (1998). "ST segment elevation induced by class IC antiarrhythmic agents: underlying electrophysiologic mechanisms and insights into drug-induced proarrhythmia". J Cardiovasc Electrophysiol. 9 (11): 1167–72. PMID 9835260.
  15. ↑ Gasparini M, Priori SG, Mantica M, Napolitano C, Galimberti P, Ceriotti C; et al. (2003). "Flecainide test in Brugada syndrome: a reproducible but risky tool". Pacing Clin Electrophysiol. 26 (1 Pt 2): 338–41. PMID 12687841.
  16. ↑ Douglas PS, Carmichael KA, Palevsky PM (1984). "Extreme hypercalcemia and electrocardiographic changes". Am J Cardiol. 54 (6): 674–5. PMID 6475795.
  17. ↑ Sridharan MR, Horan LG (1984). "Electrocardiographic J wave of hypercalcemia". Am J Cardiol. 54 (6): 672–3. PMID 6475794.
  18. ↑ MYERS GB (1950). "Other QRS-T patterns that may be mistaken for myocardial infarction; IV. alterations in blood potassium; myocardial ischemia; subepicardial myocarditis; distortion associated with arrhythmias". Circulation. 2 (1): 75–93. PMID 15427197.
  19. ↑ MERRILL JP, LEVINE HD, SOMERVILLE W, SMITH S (1950). "Clinical recognition and treatment of acute potassium intoxication". Ann Intern Med. 33 (4): 797–830. PMID 14771753.
  20. ↑ Ortega-Carnicer J, Benezet J, Ruiz-Lorenzo F, Alcázar R (2002). "Transient Brugada-type electrocardiographic abnormalities in renal failure reversed by dialysis". Resuscitation. 55 (2): 215–9. PMID 12413761.
  21. ↑ Araki T, Konno T, Itoh H, Ino H, Shimizu M (2003). "Brugada syndrome with ventricular tachycardia and fibrillation related to hypokalemia". Circ J. 67 (1): 93–5. PMID 12520160.
  22. ↑ Kasanuki H, Ohnishi S, Ohtuka M, Matsuda N, Nirei T, Isogai R, Shoda M, Toyoshima Y, Hosoda S. Idiopathic ventricular fibrillation induced with vagal activity in patients without obvious heart disease. Circulation. 1997; 95: 2277–2285.
  23. ↑ Proclemer A, Facchin D, Feruglio GA, Nucifora R (1993). "[Recurrent ventricular fibrillation, right bundle-branch block and persistent ST segment elevation in V1-V3: a new arrhythmia syndrome? A clinical case report]". Giornale Italiano Di Cardiologia (in Italian). 23 (12): 1211–8. PMID 8174872. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  24. ↑ 24.0 24.1 Mizumaki K, Fujiki A, Tsuneda T, Sakabe M, Nishida K, Sugao M, Inoue H (2004). "Vagal activity modulates spontaneous augmentation of ST elevation in the daily life of patients with Brugada syndrome". Journal of Cardiovascular Electrophysiology. 15 (6): 667–73. doi:10.1046/j.1540-8167.2004.03601.x. PMID 15175062. Retrieved 2012-10-14. Unknown parameter |month= ignored (help)
  25. ↑ Brugada R, Brugada J, Antzelevitch C, Kirsch GE, Potenza D, Towbin JA; et al. (2000). "Sodium channel blockers identify risk for sudden death in patients with ST-segment elevation and right bundle branch block but structurally normal hearts". Circulation. 101 (5): 510–5. PMID 10662748.
  26. ↑ Shimizu W, Antzelevitch C, Suyama K, Kurita T, Taguchi A, Aihara N; et al. (2000). "Effect of sodium channel blockers on ST segment, QRS duration, and corrected QT interval in patients with Brugada syndrome". J Cardiovasc Electrophysiol. 11 (12): 1320–9. PMID 11196553.
  27. ↑ 27.0 27.1 Bolognesi R, Tsialtas D, Vasini P, Conti M, Manca C (1997). "Abnormal ventricular repolarization mimicking myocardial infarction after heterocyclic antidepressant overdose". Am J Cardiol. 79 (2): 242–5. PMID 9193039.
  28. ↑ Goldgran-Toledano D, Sideris G, Kevorkian JP (2002). "Overdose of cyclic antidepressants and the Brugada syndrome". N Engl J Med. 346 (20): 1591–2. doi:10.1056/NEJM200205163462020. PMID 12015405.
  29. ↑ Tada H, Sticherling C, Oral H, Morady F (2001). "Brugada syndrome mimicked by tricyclic antidepressant overdose". J Cardiovasc Electrophysiol. 12 (2): 275. PMID 11232630.
  30. ↑ Babaliaros VC, Hurst JW (2002). "Tricyclic antidepressants and the Brugada syndrome: an example of Brugada waves appearing after the administration of desipramine". Clin Cardiol. 25 (8): 395–8. PMID 12173907.
  31. ↑ Kasanuki H, Ohnishi S, Ohtuka M, Matsuda N, Nirei T, Isogai R; et al. (1997). "Idiopathic ventricular fibrillation induced with vagal activity in patients without obvious heart disease". Circulation. 95 (9): 2277–85. PMID 9142005.
  32. ↑ Litovsky SH, Antzelevitch C (1990). "Differences in the electrophysiological response of canine ventricular subendocardium and subepicardium to acetylcholine and isoproterenol. A direct effect of acetylcholine in ventricular myocardium". Circ Res. 67 (3): 615–27. PMID 2397572.
  33. ↑ 33.0 33.1 Priori SG, Napolitano C, Gasparini M, Pappone C, Della Bella P, Giordano U; et al. (2002). "Natural history of Brugada syndrome: insights for risk stratification and management". Circulation. 105 (11): 1342–7. PMID 11901046.
  34. ↑ Morita H, Takenaka-Morita S, Fukushima-Kusano K, Kobayashi M, Nagase S, Kakishita M; et al. (2003). "Risk stratification for asymptomatic patients with Brugada syndrome". Circ J. 67 (4): 312–6. PMID 12655161.
  35. ↑ Brugada J, Brugada R, Antzelevitch C, Towbin J, Nademanee K, Brugada P (2002). "Long-term follow-up of individuals with the electrocardiographic pattern of right bundle-branch block and ST-segment elevation in precordial leads V1 to V3". Circulation. 105 (1): 73–8. PMID 11772879. Retrieved 2012-10-13. Unknown parameter |month= ignored (help)
  36. ↑ Brugada P, Brugada R, Mont L, Rivero M, Geelen P, Brugada J (2003). "Natural history of Brugada syndrome: the prognostic value of programmed electrical stimulation of the heart". Journal of Cardiovascular Electrophysiology. 14 (5): 455–7. PMID 12776858. Retrieved 2012-10-13. Unknown parameter |month= ignored (help)
  37. ↑ Eckardt L, Probst V, Smits JP, Bahr ES, Wolpert C, Schimpf R, Wichter T, Boisseau P, Heinecke A, Breithardt G, Borggrefe M, LeMarec H, Böcker D, Wilde AA (2005). "Long-term prognosis of individuals with right precordial ST-segment-elevation Brugada syndrome". Circulation. 111 (3): 257–63. doi:10.1161/01.CIR.0000153267.21278.8D. PMID 15642768. Retrieved 2012-10-13. Unknown parameter |month= ignored (help)

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