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Caso clinico: Palpitazioni, Sincope e Brugada Diana

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Caso clinico: Palpitazioni, Sincope e Brugada
Diana Solari
Centro Aritmologico e Syncope Unit, Lavagna
Santa Margherita Ligure, 4 aprile 2014
Anamnesi
• Uomo di 48 anni
• Pattern ECG tipo 2
Brugada
• Consigliato impianto
di defibrillatore
automatico presso
altro Centro
Anamnesi
•  Episodi ricorrenti di cardiopalmo notturno
•  Sincopi recidivanti con lunghi prodromi
neurovegetativi, con traumi contusivi minori
•  Familiarità negativa per malattie aritmiche (MCI)
•  Assenza di cardiopatia strutturale
•  Holter ECG delle 24 ore negativo
ICD
“In Brugada syndrome ICD therapy should
be considered in patients with in patients
with spontaneous type I ECG and
unexplained ESC
syncope
Guidelines on” Management of Syncope - Version
2009
“symptomatic patients with recurrent
syncope, agonal respiration at night during
sleep or unknown seizures are at risk of
dying suddenly without protection and have
a Class I indication for ICD treatment”
Brugada Syndrome– Two Decades of Progress –Veerakul G. et al.
circj.CJ-12-1352
Cosa fare?
Test alla flecainide ?
Studio elettrofisiologico ?
Impianto loop recorder ?
Follow-up clinico ?
Stratificazione ECG
“ Subjects at highest
risk are those with a
spontaneous type 1
ECG and at least two risk
factors (including
syncope, family history of
SD, and positive EPS);
the remainder are at low
risk. ”
Risk stratification in individuals with the Brugada type 1 ECG pattern without previous cardiac
arrest: usefulness of a combined clinical and electrophysiologic approach. Delise et al,
European Heart Journal (2011) 32, 169–176
Test alla flecainide
“In asymptomatic individuals with a non-diagnostic Br-ECG,
the incidence of events is low regardless of the sodium
channel blocker test result while in symptomatic patients
a positive sodium-channel blocker test result is
associated with an adverse arrhythmic outcome and
may contribute to risk stratification”.
Kaplan-Meier analysis of freedom from adverse events stratified by using the sodium-channel blocker
test result in symptomatic (A) and asymptomatic (B) individuals.
Should all individuals with a nondiagnostic Brugada-electrocardiogram undergo
sodium-channel blocker test? Zorzi A. et al. Heart Rhythm, Vol 9, No 6, June 2012
SEF
“VT/VF inducibility is unable
to identify high-risk
patients, whereas the
presence of a spontaneous
type I ECG, history of
syncope, ventricular effective
refractory period 200 ms, and
QRS fragmentation seem
useful to identify candidates
for prophylactic implantable
cardioverter defibrillator.”
Risk Stratification in Brugada Syndrome Results of the PRELUDE (Programmed ELectrical
stimUlation preDictive valuE) Registry Priori et al. J Am Coll Cardiol 2012;59:37–45)
ILR
“In Brugada syndrome, in the absence of
type I pattern, consider ILR”
ESC Guidelines on Management of Syncope - Version
2009
Impianto di loop recorder
Dopo 3 anni di monitoraggio (2010-2013)
il paziente ha presentato 65 episodi
documentati di palpitazioni e 4 sincopi
documentate (durante febbre, post
minzionale, post prandium)
Documentazione ILR durante palpitazioni
(monitoraggio remoto)
Documentazione ILR durante episodio sincopale
(monitoraggio remoto)
Diagnosi finale
•  Cardiopalmo non aritmico
•  Sincopi neuromediate
Terapia
•  Rassicurazione
•  Manovre isometriche di contropressione
Hand grip
Arm (muscle) tensing
11 patients with Type 1 ECG pattern (9 symptomatic, 5 spontaneous
Type 1 ECG pattern.
Follow-up 33 months
8 recurrence of symptoms
4 pts bradycardia (2 AVB, 2
SB);
6 vasovagal syncopes; 2
epilepsy.
no ventricular arrhythmia
Conclusions: The use of ILR should be considered in selected patients with
atypical syncope and spontaneous or transient Type 1 ECG pattern
Kubala M, et al. Europace 2011;14:898-902
Possibilità future
Impianto di pacemaker se sincopi
recidivanti asistoliche con impatto
sulla qualità della vita
ECG
•  ECG basale: pattern tipo 2 Brugada
•  ECG eseguito posizionando V1 V2 V3 al secondoterzo spazio intercostale: non evidenza di pattern
tipo 1.
Impianto di loop recorder
Implantable Loop Recorder and syncope: indications
Class I, B
•  ECG monitoring is indicated in patients who have clinical or ECG features
suggesting arrhythmic syncope
Class I, B
•  An early phase of evaluation in pts with recurrent syncope of uncertain origin, no
high risk criteria and high likelihood of recurrence
Class I, B
•  High risk patients in whom a comprehensive evaluation did not demostrate a
cause of syncope or lead a specific treatment
ESC Guidelines on Management of Syncope – Update 2009
Impianto di loop recorder
Indications of Implantable Loop Recorder other than
syncope:
ESC guidelines 2009:
No recommendation
EHRA Position Paper 2009:
Class II, B
ILR may be indicated in patients with T-LOC of uncertain syncopal origin in order
to definitely exclude an arrhythmic mechanism (Level of evidence C)
Test alla flecainide
•  Bloccante canali del
sodio
•  Clinicamente usato per
smascherare ECG
diagnostico per S.
Brugada (tipo 1, a tenda)
in pazienti con ECG non
diagnostici (tipo 2 e 3, a
sella)
BASALE
FLECAINIDE 140 MG EV
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