1 / 23

EKG Rounds

EKG Rounds. Elizabeth Haney 17 August 2006. Case. 26 yo Caucasian male presents to your ED with hx of a single syncopal episode. Witnessed, <1minute, no Seizure activity, alert following event. T 37.3/ HR 80reg/ BP 124/76/ RR 12 O2sat 99%RA/ BG 6.2 Asymptomatic in ED, wants to go home!

nellis
Télécharger la présentation

EKG Rounds

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. EKG Rounds Elizabeth Haney 17 August 2006

  2. Case • 26 yo Caucasian male presents to your ED with hx of a single syncopal episode. • Witnessed, <1minute, no Seizure activity, alert following event. • T 37.3/ HR 80reg/ BP 124/76/ RR 12 O2sat 99%RA/ BG 6.2 • Asymptomatic in ED, wants to go home! • What else would you like to know?

  3. Additional History • Assoc. with brief episode of palpitations prior to syncope • No SOB, Chest Pain, N/V, HA • PMHx: healthy • Meds: nil • No street drug use • FHx: No known CAD/stroke/seizure/syncope. Father died in his sleep at 34.

  4. His EKG • Any takers on Dx?

  5. Brugada Syndrome Twelve-lead surface EKG showing typical pattern of right bundle-branch block and ST-segment elevation of "coved type" in leads V1 to V3 in a patient identified after a syncopal episode

  6. Brugada Syndrome • First described in 1992 by Pedro and Josep Brugada • New syndrome: assoc. w/ SCD in pts w/ structurally normal hearts & no evidence of CAD • Pts had a distinct set of EKG abnormalities: -RBBB pattern, and persistent ST-segment elevation in the right precordial leads (V1-3).

  7. Epidemiology • Prevalence ranges vary: 0.7-1.0% in Japanese studies, 0.6% in Finnish study, 0.4% in US study. • Male:Female ratio up to 9:1. • More common in Asian populations. Up To Date

  8. Genetics • Autosomal Dominant inheritance • 15% to 30% of patients with the Brugada syndrome, mutations have been found in SCN5A, the cardiac sodium channel α-subunit gene located on chromosome 3

  9. Structural Abnormalities • BS not usually assoc. w/ structural heart dz • Evidence supporting subtle microscopic abnormalities incl. localized myocarditis or microaneurysms. Frustaci et al., Cardiac histological substrate in patients with clinical phenotype of Brugada Sundrome. Circ. 2005 Dec 13;112(24):3680-7. 18 pts in study, 14 w/ RV myocarditis, 7 w/ RV microaneurysms

  10. 3 Patterns of ST Elevation • Type 1: elevated ST segment ( >2 mm) descends with an upward convexity to an inverted T wave. = "coved type" Brugada pattern. • Type 2 and type 3 patterns have a "saddle back" ST-T wave configuration, with the elevated ST segment descends toward the baseline, then rises again to an upright or biphasic T wave. The ST segment is elevated 1 mm in type 2 and <1 mm in type 3.

  11. Brugada Waves: 3 Types ‘Coved’ ST segments w/ T wave inversion • ‘Saddleback’ ST segments • Type 2 • Positive or biphasic T wave • 1mmSTE • Type 3 • Positive T wave • <1mm STE Z Kardiol 2004; 93:784–790 Thanks Dr. Haager

  12. Differential Dx • EKG findings alone not diagnostic. • DDx: • RV pathology • Compression (tumor, hemopericardium) • Inferior MI, RV ischemia, Cardiac contusion • RBBB, LVH • Arrhythmogenic right ventricular cardiomyopathy • Drugs: class IA (procainamide…), IC (propafenone, flecainide…), cocaine, TCA’s, and more • Hyperkalemia, hypercalcemia

  13. Brugada Pattern vs Syndrome • Brugada Pattern = EKG findings without other clinical criteria • Brugada Syndrome = typical EKG findings with other clinical criteria

  14. Clinical Spectrum

  15. Clinical Manifestations • Related to life-threatening ventricular arrhythmias. • SCD occurs in as many as 1/3rd of pts! • Arrhythmic events generally occur between ages of 22-65. • More common at night and during sleep, usually not related to exercise.

  16. Diagnostic Criteria Type I • In evolution. • “Strongly consider in pts that meet the following criteria” • Type I • EKG pattern of type 1 ST segment elevation (coved type) in >1 lead of V1-V3 and 1 of: • Documented VF • Self-terminating polymorphic VT • Family Hx of SCD <45 • Other Family members w/ Brugada ECG pattern • EPS inducibility of VT • Unexplained syncope suggestive of a tachyarrhythmia • Nocturnal agonal respirations Wilde et al. Eur Heart J 2002;23:1648

  17. Diagnostic Criteria Type 2 + 3 • Type 2 or 3 • EKG pattern of type 2 or 3 ST segment elevation (saddle-back type) in >1 lead of V1-V3, with conversion to type 1 following challenge w/ a sodium channel blocker And1 of: • Documented VF • Self-terminating polymorphic VT • Family Hx of SCD <45 • Other Family members w/ Brugada ECG pattern • EPS inducibility of VT • Unexplained syncope suggestive of a tachyarrhythmia • Nocturnal agonal respirations

  18. Proposed Work-Up

  19. Treatment • Refer for EP studies • ICD placement • When provided with an ICD, mortality at 10-year follow-up has been 0%. • Quinidine (sodium channel blocker) research shows promise. Currently may have role for pts with ICD and frequent discharges (consider amiodarone, quinidine or hydroquinidine). Uptodate.com

  20. Take Home • Be familiar with the EKG manifestations of Brugada syndrome to ensure early diagnosis and prompt referral.

  21. References • Zipes: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed. • Brugada P, Brugada J: Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. J Am Coll Cardiol 1992;20:1391-1396 • Littmann et al., Brugada syndrome and “Brugada sign”: Clinical spectrum with a guide for the clinician ,American Heart Journal, 145;768-778 • Frustaci et al., Cardiac histological substrate in patients with clinical phenotype of Brugada Sundrome. Circ. 2005 Dec 13;112(24):3680-7. • Wilde et al., Proposed diagnostic criteria for the Brugada syndrome. Eur Heart J 2002; 23:1648 • Mattu et al., The Brugada Syndrome, Am J Emerg Med 2003;21:146-151 • Uptodate.com • J.,R., and P. Brugada, Determinants of Sudden Cardiac Death in Individuals With the Electrocardiographic Pattern of Brugada Syndrome and No Previous Cardiac Arrest. Circ. Dec. 2003; 108: 3092-3096

  22. Pts w/ ECG diagnostic of Brugada syndrome and no previous cardiac arrest have an 8% risk of SCD during a short-term follow-up period of 2 years. • Lowest-risk group = no syncopal episodes, diagnostic ECG only with drug challenge, and noninducibility during programmed ventricular stimulation (0.5% incidence of events). • Highest-risk group = combo of a previous history of syncope, a spontaneously abnormal ECG, and inducible sustained arrhythmias during programmed ventricular stimulation (27.2% incidence of events). J.,R., and P. Brugada, Determinants of Sudden Cardiac Death in Individuals With the Electrocardiographic Pattern of Brugada Syndrome and No Previous Cardiac Arrest. Circ. Dec. 2003; 108: 3092-3096

More Related