[SCD-FORUM] 20E RE:心悸和心脏性猝死的危险—Perez Riera医师

星期二十月 17 10:03:34 ART 2006

20E RE:心悸和心脏性猝死的危险—Perez Riera医师

阿根廷Buenos Aires 的Andriy Vorotniak医师，巴西SP的Andres  
Ricardo
Perez Riera

Brugada综合征室上性心律失常的发生率

尽管常见的心律是窦性心律，然而，在Brugada综合征 
患者中会出现发生率异常增高的房性心律失常。这一 
致心律失常性疾病并不仅仅导致室性心律失常， 
10%-25%的Brugada病例中可以出现房性心律失常。在Brugada 
兄弟最初的发现中即提及了阵发性房颤的发生，随后 
巴西和日本的研究者们也提到了这一点。后者提到阵 
发性房颤可在30%的病例中观察到。

Eckardt等在2001年发表的文章中指出约有29%的患者出现 
室上性心律失常，并指出这些心律失常为房室折返性 
室上速。
也有文献报道Brugada综合征合并有A型预激综合征（5— 
6）。有自发性房性心律失常及其他因素诱发产生室 
性心律失常的Brugada综合征患者其疾病过程是否严重 
与有否房性心律失常的病史有关。在Brugada综合征患 
者中，自发性房性心律失常与氟卡胺诱发产生的房性 
心律失常的发生率为26%和10%。在有植入ICD指征的 
Brugada患者中，房性心律失常的发生率达到27%，而无 
植入ICD指征的患者其房性心律失常的发生率仅为13%。

植入ICD患者中，14%因房性心律失常发作造成了不规则 
放电，而规则放电发生在10.5%的患者中。单腔起搏器 
的植入是ICD不规则放电的独立预测因素。在Brugada综 
合征患者中，建议仔细制定植入单腔ICD的计划以避免 
不规则放电（7）。Boveda等观察到，在一位46岁的 
Brugada综合征的患者中，房性心律失常是唯一的病理 
性节律（8）。
因此，无论是依据文献抑或依据Boveda的个人经验，应 
当重性考虑Brugada患者室上性心律失常的患病率。
一位41岁的Brugada男性患者，既往无心脏性猝死或晕 
厥，因症状性房颤在当地急诊。血液生化检查提示低 
钾血症（2.9mEq/L）。其他指标都在正常范围中。很 
快，这位患者出现了室颤，并用150J双相除颤仪进行 
除颤。之后的2小时内，这位患者反复发生室速、室 
颤。每次应用150J双相除颤仪除颤均能有效地转复为 
窦性心律。在血钾水平恢复正常之后，该患者不再发 
生室速、室颤。在他出院前，植入了ICD以避免心脏猝 
死的发生。
低钾血症能增加Brugada综合征心律失常的发生危险（9、 
10）。窦房结功能不全在Brugada综合征中并不少见，并 
且可能有遗传因素。窦房结功能不全多合并房颤的发 
生。（11）

参考文献

1) 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

2) Villacorta H, Faig Torres RA, SimF5es de  Castro IR, Lambert H. de
Araujo Gonzales Alonso R.: Morte subita em paciente com bloqueio de
ramo direito e elevacao persistente do segmento ST. Arq  Bras
Cardiol. 1996; 66:( N4) 229-231

3) Itoh H, Shimizu M, Ino H, et al. Hokuriku Brugada Study Group.
Arrhythmias in-patients with Brugada-type electrocardiograph findings.
Jpn Circ J 2001; 65:483-6

4) Eckardt L, Kirchhof P, Loh P, et al. Brugada Syndrome and
Supraventricular Tachyarrhythmias: A Novel Association? J Cardiovasc
Electrophysiol 2001; 12:680-685

5) Eckardt L, Kirchhof P, Johna R, Haverkamp W, Breithardt G, Borggrefe
M. : Wolff-Parkinson-White syndrome associated with Brugada syndrome.
Pacing Clin Electrophysiol 2001;24(9 Pt 1):1423-4.

6) Bodegas AI, Arana JI, Vitoria Y, Arriandiaga JR, Barrenetxea JI.
Brugada syndrome in a patient with accessory pathway. Europace 2002;
4:87-9

7) Bordachar P, Reuter S, Garrigue S, Cai X, Hocini M, Jais P,
Haissaguerre M, Clementy J. Incidence, clinical implications and
prognosis of atrial arrhythmias in brugada syndrome.Eur Heart J.
2004;25:879-884.

8) Boveda S, Combes N, Albenque JP, et al. Brugada syndrome and
supraventricular arrhythmiasArch Mal Coeur Vaiss. 2004; 97: 688-692.

9) Notarstefano P, Pratola C, Toselli T, et al. Atrial fibrillation
and recurrent ventricular fibrillation during hypokalemia in Brugada
syndrome. Pacing Clin Electrophysiol. 2005; 28:1350-1353.

10) Notarstefano P, Pratola C, Toselli T, et al Atrial fibrillation
and recurrent ventricular fibrillation during hypokalemia in Brugada
syndrome.

11) Sumiyoshi M, Nakazato Y, Tokano T,  Sinus node dysfunction
concomitant with Brugada syndrome. Circ J. 2005; 69:946-950.

祝好

Andrés Ricardo Pérez Riera
心脏病学心电向量学部，FMABC，FUABC主任
- 圣安德雷- 圣保罗- 巴西
Sebastião Afonso街885 – 邮编: 044417-100- Jardim Miriam  S.P
巴西-
毛晔译  王玲洁校

Sergio Dubner医师
科委会主席
Edgardo Schapachnik医师
组委会主席

20E RE: Palpitations and SCD risk. Dr. Perez Riera

Dr. Andriy Vorotniak from Buenos Aires, Argentina. Here Andres Ricardo
Perez Riera from SP Brazil.

THE INCIDENCE OF SUPRAVENTRICULAR ARRHYTHMIAS IN THE BRUGADA SYNDROME

Sinus rhythm is the usual; however, Brugada syndrome (BrS) patients
exhibit an abnormally high proportion of atrial arrhythmias that are
found in 10 to 25% of cases since the arrhythmogenic substrate is
not  limited to the ventricles. In the original discovery by the Brugada
brothers (1992)(1), temporary AF was mentioned, as well as by authors
from Brazil (2) and from Japan (3).  The latter mentioned that the
paroxysmal form
of AF is observed in a 30% of cases.

A publication by Eckardt L et al (2001) (4), indicates a frequency
for supraventricular arrhythmias of 29%. These authors described
episodes of
AV supraventricular tachycardia with reentry.

There are references of Wolff-Parkinson-White syndrome A type
associated to BrS (5-6).

There is a more advanced disease process in BrS patients with
spontaneous atrial arrhytmias and ventricular inducibility was
significantly related to a history of atrial arrhythmias.The  
incidence  of atrial arrhythmias in  patients with a spontaneous  
electrocardiogram  of BrS was 26% vs 10%  in patients with a  
flecainide-induced ECG.In patients with an indication of ICD, the   
incidence of atrial arrhythmias reached 27% vs 13% in patients with   
BrS but without ICD indication;

Inappropriate shocks due to atrial arrhythmias episodes were observed
in 14% of ICD patient's vs 10.5% of appropriate shocks;The  
implantation of a single-chamber device is as an independent   
predictive factor of inappropriate ICD discharges;

Careful programming of single-chamber ICD should be recommended to
avoid inappropriate discharges in patients with BrS (7).

Arrhythmia of atrial origin was the only spontaneous pathologic   
rhythmic observed in a 46 years old man patient with BrS by Boveda  
et  al (8).
Consequently it led to reconsider its prevalence in patients   
presenting this syndrome both in the literature and according   
Boveda's time  personal experience.

A 41-year-old man with BrS and no previous episodes of aborted SCD or
syncope referred to local emergency room for an episode of   
symptomatic  AF. Blood chemistry results showed hypokalemia(2.9 mEq/ 
L). The other parameters were  within the normal range. After few  
minutes, an episode of VF treated  with biphasic DC shock 150 J    
occurred. In successive 2  hours, the patient experienced recurrent   
episodes of VT and VF. Each  biphasic DC shock 150 J was effective  
to  restore sinus rhythm. No
further episodes occurred after normalization of serum levels of    
potassium. Before discharge, an ICD was inserted to prevent SCD.
Hypokalemia increases the risk of arrhythmic events in BrS (9).
Hypokalemia increases the risk of arrhythmic events in BrS(10).

Sinus node dysfunction (SND)  is not a rare concomitant disorder in
BrS and there is a possible genetic connection. SND is associated
with AF(11).

References