de repolarisation prcoce? Frdric Sacher Hopital Cardiologique du - - PowerPoint PPT Presentation

Frédéric Sacher

Hopital Cardiologique du Haut Lévêque LIRYC Institute, INSERM 1045 CHU de Bordeaux / Université de Bordeaux France

Quel bilan devant un aspect de repolarisation précoce?

Disclosures

– Speaking honorarium: Biosense Webster, Boston Scientific, Medtronic, Abbott, Microport, Boehringer Ingelheim, Bayer, Pfizer, BMS/Pfizer – Consulting fees: Abbott, Bayer Healthcare,

Early Repolarization: Definition

• Slurring (late delta) or

notch at the end of QRS, with J point>0.1mV (1mm) in ≥ 2 leads

• Left precordial and/or

inferior and/or lateral ECG leads (excluding V1-V3 for Brugada/ARVD)

* * * * * * * * * *

Inferior distribution Infero-lateral distribution

Haissaguerre M. et al. JICE 2007; Haissaguerre M et al. N Engl J Med 2008; Mac Farlane P. et al. JACC 2015

QRS slurring w/o ST elevation QRS slurring with ST elevation QRS notching with ST elevation QRS notching w/o ST elevation

○ ○ ≥ ○ ≥ ○ ○ ○ ○ ≥ ○ ≥ ○ ○ ○ ○ ≥ ○ ≥ ○ ○ ○ ○ ≥ ○ ≥ ○ ○ ○ ○ ≥ ○ ≥ ○ ○ ○ ○ ≥ ○ ≥ ○ ○

ST segment elevation is not sufficient for the diagnosis. J-wave/point elevation is necessary !!

D2 Jp Jo Je D1

Notch Slur

J wave elevation measurement

MacFarlane PW et al. The ER Pattern: A Consensus Paper. JACC 2015

Est-ce que tu validerais la repolarisation précoce en inférieur? Patient totalement asymptomatique et présentant un bloc de branche droit Pour quelle raison ne retiens-tu pas repo précoce ? Est-ce à cause du bloc de branche droit ?

Demande d’avis par mail

Evidences of the pathological relationship between J wave elevation and SCD

1- Prevalence of « early repolarisation »

• 31% in pts with IVF vs 5% in the matched group (p=0.002)
• 31% in pts with IVF vs 9% in controls (Rosso et al. JACC 08)
• 206 pts with resuscitated Idiopathic Ventricular Fibrillation in 24

tertiary care arrhythmia centres (No structural heart disease)

• Matched with 412 healthy subjects (normal ECG and echo) for age,

sex, ethnicity, sport.

Population

 Ethnicity: No african or

african/american people

 Athletes:

– None in Haissaguerre et al. NEJM 2008 – 121 In Rosso et al. JACC 2008 12% of J point elevation >0.1mV

Definition 19 athletes with CA vs 365 control

Evidences of the pathological relationship between J wave elevation and SCD

1- Prevalence of « early repolarisation »

• 31% in pts with IVF vs 5% in the matched group (p=0.002)
• 31% in pts with IVF vs 9% in controls (Rosso et al. JACC 08)

2- Amplitude of J point

• 2.15±1.2mm in IVF vs 1.05±0.2mm in controls with « early repolarisation »

3- Dynamicity of J wave: Accentuation of the pattern at the time of Arrhythmias

• Maximal J point elevation of 4.1 ±2mm (2 to 10 mm)

4- Correlation location J/ST and Arrhythmia origin

• Early Repolarization Pattern Vs. Early Repolarization

Syndrome

• ER pattern is frequent in general population (1 to 9%)
• Sudden Cardiac Death in young healthy adult is extremely

rare

• Data suggest: J-wave discovery in a young adult increase

risk of SCD:

• X 3

What is the risk associated with ER?

• Early Repolarization Pattern Vs. Early Repolarization

Syndrome

• ER pattern is frequent in general population (1 to 9%)
• Sudden Cardiac Death in young healthy adult is extremely

rare

• Data suggest: J-wave discovery in a young adult increase

risk of SCD:

• X 3
• from 3.4:100,000 to 11:100,000 (Rosso et al. JACC 2008)

What is the risk associated with ER?

Who is at risk?

• 1. Familial sudden cardiac death <45 yo
• 2. Previous aborted cardiac death
• 3. Presyncope or syncope ++
• 39% of patients with cardiac arrest had a history of syncope

Clinical Features

Follow-up of patients with Syncope and ER

• Multicentric study (17centers)
• 63 pts (33yo, 54males)
• 37 with ILR or ICD
• 3 recorded Polymorphic VT on ILR (mean f/u 7 months)

Maury P et al. EUROPACE 2011 ; Le Bloa et al. HRS 2012

 J-point elevation in inferior leads

– >0.1mV (5.8%) RR cardiac death: 1.30 (CI:1.05 – 1.61, p=0.02) – >0.2 mV (0,33%) RR cardiac death: 3.03 (CI 1.88-4.90, p=0.001)  RR arrhythmic death: 2.99 (CI 1.49-6.03, p=0.005) Stronger predictors than QT interval and LVH

N Engl J Med. 2009 Nov 16

ECG

H 34yr, convulsions while sleeping. 2 ECGs the same day

7h

Dynamic Entity

15h

Gourraud JB et al. JACC 2013

Vasalva maneuvers

ECG

Mean J wave amplitudes and VF recurrence

P=0.004 P=0.24 P=0.002 P=0.12

Inferior J waves High lat. J waves Lateral J waves Global J waves

Boxplots show median, lower/upper quartiles, minimum, maximum and outliers. Y axis shows mV in all graphs Roten, Derval et al. Cardiostim 2012

J-wave morphology

• Notch morphology more prevalent in IVF population

especially in left precordial

• 44% Vs. 8% p=.001
• Small case-control study and one population study

(Rollin et al. Am J Cardiol 2012)

• Not reported in larger study

Tikkanen J et al. Circulation 2011 (Risk of arrhythmic death: HR 3.14 – 1.56-6.30)) Rosso R et al. Heart Rhythm 2011 (Risk of idiopathic VF OR: 13.8 (CI 5.1-37.2)) Rollin A et al. Am J Cardiol 2012 (Risk of cardiovascular mortality HR: 8.75 (CI 3.48-22))

Ascending ST segment

 benign outcome

Horizontal/descending ST segment

 poorer outcome

Horizontal/descending ST segment

EPS & Early Repolarization?

No Pharmacological test to depict malignant Early Repolarization

– No change : verapamil , epinephrine, ATP, cibenzoline, pilsicainide, Ca – Slight accentuation : bradycardia, Betablockers – Decrease or no change: Ajmaline, flecainide – Decrease with Exercise/Isoproterenol and under Quinidine*. Both are powerful treatments for arrhythmic storms or multiple VF.

Roten, derval et al. Heart rhythm Roten, derval et al. Heart rhythm 2012; 9:232-9

Implantable Cardioverter Defibrillator

Antzelevitch et al. J WAVE SYNDROMES EXPERT CONSENSUS CONFERENCE: Emerging Concepts & Gaps in Knowledge. Heart Rhythm 2016

32 yo asymptomatic male systematic ECG

35 yo asymptomatic male systematic ECG Vasalva maneuvers

Valsalva maneuver

Valsalva maneuver: end

Is it a benign ECG?

36 yo female, no familial history, no medical history

Bernard A et al. JICE 2009

10 yo girl with syncope Brother died suddenly at 17

Courtesy of Vincent Probst( CHU de Nantes, France)

One month after quinidine start

Is it a benign ECG?

Should this patient be left alone?

34 yo asymptomatic patients His brother died suddenly 6 month ago (during sleep) Courtesy of Olivier Piot ( CCN, France)

Conclusions

 A small subset of patients with ER will have VF:

– RISK STRATIFICATION: resuscitated SCD, syncope and major J wave elevation/horizontal ST segment.

 If asymptomatic, no familial history of SD and standard ER

pattern (1mm J wave elevation)  NOTHING

 Otherwise:

– ECG with Vasalva maneuvers, TTE, Holter ECG, +/- Stress test and refer to expert cardiologist – In case of severe history of familial SCD or atypical lightheadednes

• -- > Implantable loop recorder