<HTML><BODY style="word-wrap: break-word; -khtml-nbsp-mode: space; -khtml-line-break: after-white-space; "><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Dear Dr. Vorotniak,</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; font: normal normal normal 13px/normal Lucida Grande; min-height: 16px; "><FONT class="Apple-style-span" face="Arial" size="3"><SPAN class="Apple-style-span" style="font-size: 12px;"><BR></SPAN></FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">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. </FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; font: normal normal normal 13px/normal GB18030 Bitmap; min-height: 17px; "><FONT class="Apple-style-span" face="Arial" size="3"><SPAN class="Apple-style-span" style="font-size: 12px;"><BR></SPAN></FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">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):96101.</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">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):56971.</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">3. Hashimoto T., Fucatani M., et al. Effects of stending on the of Paroxysmal Supraventricular Tachycardia. JASS. 1991. Vol. 17. N 3. p. 650695.</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; font: normal normal normal 13px/normal Lucida Grande; min-height: 16px; "><FONT class="Apple-style-span" face="Arial" size="3"><SPAN class="Apple-style-span" style="font-size: 12px;"><BR></SPAN></FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">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. </FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">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.)</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; font: normal normal normal 13px/normal Lucida Grande; min-height: 16px; "><FONT class="Apple-style-span" face="Arial" size="3"><SPAN class="Apple-style-span" style="font-size: 12px;"><BR></SPAN></FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Dr. Leonid Macarov</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Institute of Pediatrics and Child Surgery (Moscow, Russia)</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">leo @oss.ru</FONT></DIV><FONT class="Apple-style-span" face="Arial"><BR></FONT><DIV><BLOCKQUOTE type="cite"><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; min-height: 14px; "><FONT class="Apple-style-span" face="Arial"><BR></FONT></DIV> <DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Dear colleagues, </FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">I would like to ask some questions about the prognostic value of "palpitations" in Brugada and Long QT syndromes:</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; font: normal normal normal 13px/normal Lucida Grande; min-height: 16px; "><FONT class="Apple-style-span" face="Arial" size="3"><SPAN class="Apple-style-span" style="font-size: 12px;"><BR></SPAN></FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">1.</FONT><SPAN class="Apple-tab-span" style="white-space:pre"> </SPAN><FONT class="Apple-style-span" face="Arial">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)?</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">2.</FONT><SPAN class="Apple-tab-span" style="white-space:pre"> </SPAN><FONT class="Apple-style-span" face="Arial">How do we continue the evaluation of this patient, if in the electrophysiological study there is no ventricular arrhythmia triggered? </FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">3.</FONT><SPAN class="Apple-tab-span" style="white-space:pre"> </SPAN><FONT class="Apple-style-span" face="Arial">Is there any relationship between the mentioned syndromes and supraventricular tachyarrhythmia incidence? </FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; font: normal normal normal 13px/normal GB18030 Bitmap; min-height: 17px; "><FONT class="Apple-style-span" face="Arial" size="3"><SPAN class="Apple-style-span" style="font-size: 12px;"><BR></SPAN></FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Thank you very much, </FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Dr. Andriy Vorotniak</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Buenos Aires, Argentina</FONT></DIV><BR class="khtml-block-placeholder"><FONT class="Apple-style-span" face="Arial"></FONT></BLOCKQUOTE></DIV><BR><BR><DIV> <SPAN class="Apple-style-span" style="border-collapse: separate; border-spacing: 0px 0px; color: rgb(0, 0, 0); font-family: Helvetica; font-size: 12px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: normal; text-align: auto; -khtml-text-decorations-in-effect: none; text-indent: 0px; -apple-text-size-adjust: auto; text-transform: none; orphans: 2; white-space: normal; widows: 2; word-spacing: 0px; "><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">--</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Dr.<SPAN class="Apple-converted-space"> </SPAN>Sergio<SPAN class="Apple-converted-space"> </SPAN>Dubner</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">President<SPAN class="Apple-converted-space"> </SPAN>of<SPAN class="Apple-converted-space"> </SPAN>Scientific<SPAN class="Apple-converted-space"> </SPAN>Committee</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; font: normal normal normal 13px/normal Lucida Grande; min-height: 16px; ; font-family: Lucida Grande; font-size: 13px; "><BR style="font-family: Lucida Grande; font-size: 13px; "></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">Dr.<SPAN class="Apple-converted-space"> </SPAN>Edgardo<SPAN class="Apple-converted-space"> </SPAN>Schapachnik</DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; ">President<SPAN class="Apple-converted-space"> </SPAN>of<SPAN class="Apple-converted-space"> </SPAN>Steering<SPAN class="Apple-converted-space"> </SPAN>Committee</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV><BR class="khtml-block-placeholder"></DIV><BR class="Apple-interchange-newline"></SPAN> </DIV><BR></BODY></HTML>