[SCD-FORUM] 14R RE: Palpitations and SCD risk. Dr. Makarov

[SCD Symposium]

Dear Dr. Vorotniak,

I think that you mentioned a very important issue: the evaluation of  
the prognostic value of clinical symptoms, which may be concomitant  
to diseases with high risk of SCD. In general, syncopes and  
"palpitations" that occur in patients with 2nd or 3rd degree AV  
block, and also in Long QT and Brugada syndromes, have arrhythmogenic  
origin. For this reason, aggressive antiarrhythmic treatment  
(implantation of pacemaker, antiarrhythmic drugs, etc.) is indicated.  
However, it is often observed in patients with AV block, that after  
pacemaker implantation, syncope episodes continue happening and no  
arrhythmias are detected during Holter monitoring. The probability of  
vasovagal syncopes in patients with Brugada and Long QT syndromes has  
not been well studied yet. As to "palpitations", it is worth  
mentioning that up to 16% of patients of all nosological groups may  
present this symptom (Kroenke K et al.The prevalence of symptoms in  
medical outpatients and the adequacy of therapy. Arch Intern Med .  
1990;150). Moreover, "palpitations" do not always correspond to  
arrhythmias. In year 1836, J.C. Williams mentioned that often times,  
"palpitations" are mistakenly considered to be an equivalent of  
structural heart diseases. But it is not so, because the influences  
of the nervous system have a very important role, both in the normal  
state and during some diseases. According to different data, in 35%  
to 85% of the cases, "palpitations" are recorded in a normal ECG.

1.     Baratta L, Maffe o N , Tubani L, Paradiso M, Molaioni C ,  
Coppotelli L, Lagana B, Mastrocola C , Cordova C. Arrhythmias in the  
aged : prevalence and correlation with symptoms]. Recenti Prog Med  
1996 Mar;87(3):96–101.
2.     Goldberg AD, Raftery EB, Cashman PM. Ambulatory  
electrocardiographic records in patients with transient cerebral  
attacks or palpitation. Br Med J 1975 Dec 6;4(5996):569–71.
3.     Hashimoto T., Fucatani M., et al. Effects of stending on the  
of Paroxysmal Supraventricular Tachycardia. JASS. — 1991. –Vol. 17. – 
N 3. — p. 650–695.

Our data from the pediatric population show that 30% of  
"palpitations" have a nonarrhythmogenic origin (Makarov et al,  
Pediatrics (Moscow) 2005; 2:4-8) and they occur due to psychological  
causes or autonomous nervous system disorders. Therefore, we assume  
that the "gold standard" to confirm the arrhythmogenic origin of  
"palpitations" would be to record them during the same episode, or  
cause these arrhythmias, accompanied by the corresponding symptoms,  
during ergometer test or transesophageal electrostimulation.
As to the clinical value of "palpitations" –in patients with short QT  
interval, Brugada syndrome, arrhythmogenic RV dysplasia, or short PR  
interval- this symptom may indicate the need for a more aggressive  
antiarrhythmic treatment, mostly if arrhythmias are detected (in  
Holter monitoring, EPS, ergometer) or if there are some additional  
risk factors (syncopes, family background of SCD, T wave alternans in  
patients with long QT syndrome, etc.)

Dr. Leonid Macarov
Institute of Pediatrics and Child Surgery (Moscow, Russia)
leo @oss.ru

>
> Dear colleagues,
> I would like to ask some questions about the prognostic value of  
> "palpitations" in Brugada and Long QT syndromes:
>
> 1.	What is the risk of SCD in a young patient with no underlying  
> heart disease or hereditary-familial background for SCD, with  
> Brugada syndrome (or Long QT) ECG pattern, and aborted and isolated  
> episodes of "palpitations" (not recorded with Holter monitoring)?
> 2.	How do we continue the evaluation of this patient, if in the  
> electrophysiological study there is no ventricular arrhythmia  
> triggered?
> 3.	Is there any relationship between the mentioned syndromes and  
> supraventricular tachyarrhythmia incidence?
>
> Thank you very much,
> Dr. Andriy Vorotniak
> Buenos Aires, Argentina
>


--
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee




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