Transcript Clinical presentation Basal ECG

Prognostic stratification of the subjects with a Brugada
electrocardiogram: the role of programmed electrical stimulation
with 2 and 3 extrastimuli
Natascia Cerrato MD*, Carla Giustetto MD*, Angela Del Grosso MD*, Andrea Mazzanti MD*, Elena Marras MD†, Giuseppe Allocca MD†, Miriam Bortnik MD§, Paola Dalmasso MS‡, Riccardo
Riccardi MD[], Pietro Delise MD† and Fiorenzo Gaita MD*.
Cardiology Department, Cardinal Massaia Hospital, Asti and S. Giovanni Battista Hospital, Torino, University of Torino; † Division of Cardiology, S. Maria dei Battuti Hospital, Conegliano ; §Division of Cardiology,
Ospedale Maggiore della Carità, Novara; ‡ Medical Statistics Unit, Department of Public Health and Microbiology, University of Torino; []Division of Cardiology, E. Agnelli Hospital, Pinerolo.
Supported by a grant from the “Fondazione Cassa di Risparmio” of Asti.
Brugada syndrome is an arrhythmogenic disease characterized by increased risk of sudden death (SD) and an implantable cardioverter defibrillator (ICD) is the only
effective treatment. We evaluated the role of programmed electrical stimulation (PES) in the risk stratification of subjects with a Brugada ECG, comparing the
predictive value of stimulation protocols with 2 and 3 extrastimuli.
Two hundred and eighty-six patients with spontaneous or drug-induced type 1 Brugada ECG were consecutively enrolled in 2 areas of Northern Italy, Piedmont and
Veneto regions. PES was performed in 221 patients (77%), with a maximum of 2 extrastimuli in 94 (group A), while 127 were studied up to the third extrastimulus
(group B). Documented VF, sustained VT, SD and appropriate ICD shocks were considered arrhythmic events.
- Mean age was 44±14 years.
- Ventricular fibrillation (VF) was induced in 39% of group A and in 40% of group B.
Clinical presentation
64%
34%
- None of the patients with syncope and negative PES had
arrhythmic events at follow-up.
- During a follow-up of 38±28 months the incidence of SD/VF was 1.6% per year in
the whole population, 11.7% per year in the patients with aborted SD, 2,4% per year
in those with syncope and 0.6% in the asymptomatic.
Syncope
97 pts
- The predictors of arrhythmic events were induction of VF (p=0.001), syncope
(p=0.019) and spontaneous diagnostic ECG (p=0.03).
Spontaneous
type 1 ECG
52 pts
- None of the patients with negative PES had SD/VF.
Drug induced
type 1 ECG
45 pts
p=0.009
1.00
3/5(60%)
50
100
150
Syncope
aSD
Negative
PES
24 pts
5
0
arrhytmic arrhytmic
events
events
p=0.001
Positive
PES
18 pts
NO PES
5 pts
1
arrhytmic
event
2
arrhytmic
events
Negative
PES
18 pts
NO PES
9 pts
0
0
arrhytmic arrhytmic
events
events
Arrhythmic events in the pts with syncope (follow-up 38±28 months)
0
50
100
150
Follow-up (months)
Follow-up (months)
Asymptomatic
Positive
PES
23 pts
10/88(11%)
0.50
0.50
Spontaneous type-1 ECG
Drug induced type-1 ECG
0
Arrhythmic events
0.75
8/97 (8.2%)
0.00
49%
0.25
Basal ECG
51%
3/183(1.6%)
0.75
asymptomatic
syncope
aSD
Arrhythmic events
0.00 0.25
1.00
2%
Negative PES
Positive PES
- Both stimulation protocols showed high negative predictive value
(NPV) and sensitivity.
-PES positive predictive value (PPV) was particularly low in the
asymptomatic patients.
PES
2 extrastimuli
PES
CI 95%
3 extrastimuli
CI 95%
- Aborted SD, history of syncope, spontaneous type 1 ECG and induction of VF at PES were all predictors of
arrhythmic events during the follow-up;
Sensitivity
100%
(59.0-100)
Sensitivity
100%
(29.2-100)
- PES resulted to be useful especially for risk stratification of patients with syncope of unknown origin, while
the best approach to the asymptomatic individuals has still to be established;
Specificity
66%
(54.5-75.4)
Specificity
61%
(52.1- 69.9)
PPV
19%
(8.0-35.2)
PPV
6%
(1.23-16.2)
NPV
100%
(93.7-100)
NPV
100%
(95.3-100)
- PES with up to 3 extrastimuli did not show a greater accuracy in predicting outcome than PES with a
maximum of 2 extrastimuli
Contact: [email protected]