ΗΚΓ σε Επιζώντα Αιφνίδιου Θανάτου ΠΑΝΑΓΙΩΤΗΣ ΚΟΡΑΝΤΖΟΠΟΥΛΟΣ Επίκουρος Καθηγητής Καρδιολογίας Α Καρδιολογική Κλινική Πανεπιστημίου Ιωαννίνων
Παρουσίαση Περιστατικού Άνδρας 58 ετών υπερτασικός προσκομίσθηκε στο ΤΕΠ του νοσοκομείου μας Μάιος 2015 και νοσηλεύθηκε στη ΜΕΘ ABORTED SUDDEN CARDIAC DEATH Ενώ περπατούσε στην πόλη ζάλη- αίσθημα παλμών κατάρριψη / αιμοδυναμική αστάθεια
ΜΟΛΙΣ ΚΑΤΕΦΘΑΣΕ ΤΟ ΕΚΑΒ ΒΡΕΘΗΚΕ ΑΣΦΥΓΜΟΣ - ΚΟΙΛΙΑΚΗ ΜΑΡΜΑΡΥΓΗ ΕΠΙΤΥΧΗΣ ΗΛΕΚΤΡΙΚΗ ΑΝΑΤΑΞΗ
Παρουσίαση Περιστατικού Δεν ανακαλύφθηκε αναστρέψιμο αίτιο της αρρυθμίας (ηλεκτρολυτική διαταραχή, οξεία ισχαιμία, κλπ.) Στεφανιογραφικός έλεγχος: στεφανιαία αγγεία χωρίς μείζονες στενώσεις. Υπερηχοκαρδιογράφημα: ήπια υπερτροφία αρ.κοιλίας, ΔΕ κοιλία κ.φ., βαλβίδες κ.φ., LVEF 60%
Συνέχεια περιστατικού Καλή νευρολογική εικόνα αποσωληνωμένος 3 μέρες μετά Χορηγούμενη αγωγή: Inohep, Colistin, Tazocin, Adalat, Lobivon, Diovan
Βασικό ΗΚΓ 12 απαγωγών
Baseline ECG High precordial leads (V1-V2)
Drug challenge - Pronestyl 10 mg/kg- Initiation
High V1-V2 / Initiation of drug challenge
10 th minute - End of Pronestyl Challenge
ΕΡΩΤΗΜΑΤΑ Ήταν σωστή η διάγνωση του συνδρόμου Brugada? Ο ασθενής είχε παρόμοια ΗΚΓ πολλά χρόνια πριν Μπορούσε να έχει διαγνωσθεί νωρίτερα? Μπορούσε να είχε προβλεφθεί το ατυχές συμβάν? Μπορούσε να έχει λάβει ICD νωρίτερα?
Expert Consensus Recommendations on BrS Diagnosis 1. BrS is diagnosed in patients with ST-segment elevation with type I morphology 2 mm in 1 lead among the right precordial leads V 1,V 2 positioned in the 2nd, 3rd, or 4th intercostal space occurring either spontaneously or after provocative drug test with intravenous administration of Class I antiarrhythmic drugs. 2. BrS is diagnosed in patients with type 2 or type 3 STsegment elevation in 1 lead among the right precordial leads V 1,V 2 positioned in the 2nd, 3rd, or 4th intercostal space when a provocative drug test with intravenous administration of Class I antiarrhythmic drugs induces a type I ECG morphology.
d > 4mm Type 2 Brugada
Expert Consensus Recommendations on BrS Therapeutic Interventions Class I The following lifestyle changes are recommended in all patients with diagnosis of BrS: a. Avoidance of drugs that may induce or aggravate ST-segment elevation in right precordial leads (e.g., Brugadadrugs.org) b. Avoidance of excessive alcohol intake c. Immediate treatment of fever with antipyretic drugs. ICD implantation is recommended in patients with a diagnosis of BrS who: a. Are survivors of a cardiac arrest and/or b. Have documented spontaneous sustained VT with or without syncope.
Expert Consensus Recommendations on BrS Therapeutic Interventions Class IIa ICD implantation can be useful in patients with a spontaneous diagnostic type I ECG who have a history of syncope judged to be likely caused by ventricular arrhythmias. Quinidine can be useful in patients with a diagnosis of BrS and history of arrhythmic storms defined as more than two episodes of VT/VF in 24 hours. Quinidine can be useful in patients with a diagnosis of BrS who: a. Qualify for an ICD but present a contraindication to the ICD or refuse it and/or b. Have a history of documented supraventricular arrhythmias that require treatment. Isoproterenol infusion can be useful in suppressing arrhythmic storms in BrS patients.
Expert Consensus Recommendations on BrS Therapeutic Interventions Class IΙb ICD implantation may be considered in patients with a diagnosis of BrS who develop VF during programmed electrical stimulation (inducible patients). Quinidine may be considered in asymptomatic patients with a diagnosis of BrS with a spontaneous type I ECG. Catheter ablation may be considered in patients with a diagnosis of BrS and history of arrhythmic storms or repeated appropriate ICD shocks.
Ο ασθενής μας.
SCD risk in asymptomatic BS Pedro Brugada series Even patients without any high risk characteristics have a 3% risk of events at 10 years (unpublished data). This figure is low but is 100Χ the risk of SCD in a matched healthy person.
P.Brugada series (unpublished data)
Am J Cardiol 2015;116:98-103
Presenting ECG, n (%) Spontaneous type 1 pattern 696 (53%) Drug-induced type 1 pattern 616 (47%) Induction was associated with cardiac events during follow-up (hazard ratio, 2.66; 95% confidence interval [CI], 1.44 4.92, P<0.001), with the greatest risk observed among those induced with single or double extrastimuli. Annual event rates varied substantially by syncope history,presence of spontaneous type 1 ECG pattern, and arrhythmia induction. Circulation 2016;133:622-630
Arrhythmia & Electrophysiology Review 2016
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