<HTML><BODY style="word-wrap: break-word; -khtml-nbsp-mode: space; -khtml-line-break: after-white-space; "><DIV>Dr. Andriy Vorotniak from Buenos Aires, Argentina. Here Andres Ricardo </DIV><DIV>Perez Riera from SP Brazil.</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>THE INCIDENCE OF SUPRAVENTRICULAR ARRHYTHMIAS IN THE BRUGADA SYNDROME</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>Sinus rhythm is the usual; however, Brugada syndrome (BrS) patients exhibit an abnormally high proportion of atrial arrhythmias that are </DIV><DIV>found in 10 to 25% of cases since the arrhythmogenic substrate is not limited to the ventricles. In the original discovery by the Brugada </DIV><DIV>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 </DIV><DIV>of AF is observed in a 30% of cases.</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>A publication by Eckardt L et al (2001) (4), indicates a frequency for supraventricular arrhythmias of 29%. These authors described episodes of </DIV><DIV>AV supraventricular tachycardia with reentry.</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV> There are references of Wolff-Parkinson-White syndrome A type associated to BrS (5-6).</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>There is a more advanced disease process in BrS patients with spontaneous atrial arrhytmias and ventricular inducibility was significantly related to a </DIV><DIV>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 </DIV><DIV>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;</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>Inappropriate shocks due to atrial arrhythmias episodes were observed in 14% of ICD patient's vs 10.5% of appropriate shocks;</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>The implantation of a single-chamber device is as an independent predictive factor of inappropriate ICD discharges; </DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>Careful programming of single-chamber ICD should be recommended to avoid inappropriate discharges in patients with BrS (7).</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>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). </DIV><DIV>Consequently it led to reconsider its prevalence in patients presenting this syndrome both in the literature and according Boveda's time personal experience.</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>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 </DIV><DIV>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</DIV><DIV> 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 </DIV><DIV>further episodes occurred after normalization of serum levels of potassium. Before discharge, an ICD was inserted to prevent SCD. </DIV><DIV>Hypokalemia increases the risk of arrhythmic events in BrS (9). Hypokalemia increases the risk of arrhythmic events in BrS(10).</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>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). </DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>References</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>1) Brugada P, Brugada J. Right bundle branch block, persistent ST </DIV><DIV>segment elevation and sudden cardiac death: A distinct clinical and </DIV><DIV>electrocardiographic syndrome. J Am Coll Cardiol 1992, 20: 1391-1396</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>2) Villacorta H, Faig Torres RA, SimF5es de Castro IR, Lambert H. de </DIV><DIV>Araujo Gonzales Alonso R.: Morte subita em paciente com bloqueio de </DIV><DIV>ramo direito e elevacao persistente do segmento ST. Arq Bras Cardiol. 1996; 66:( N4) 229-231</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>3) Itoh H, Shimizu M, Ino H, et al. Hokuriku Brugada Study Group. </DIV><DIV>Arrhythmias in-patients with Brugada-type electrocardiograph findings. </DIV><DIV>Jpn Circ J 2001; 65:483-6</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>4) Eckardt L, Kirchhof P, Loh P, et al. Brugada Syndrome and </DIV><DIV>Supraventricular Tachyarrhythmias: A Novel Association? J Cardiovasc </DIV><DIV>Electrophysiol 2001; 12:680-685</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV>5) Eckardt L, Kirchhof P, Johna R, Haverkamp W, Breithardt G, Borggrefe </DIV><DIV>M. : Wolff-Parkinson-White syndrome associated with Brugada syndrome. </DIV><DIV>Pacing Clin Electrophysiol 2001;24(9 Pt 1):1423-4.</DIV><DIV><BR class="khtml-block-placeholder"></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">6) Bodegas AI, Arana JI, Vitoria Y, Arriandiaga JR, Barrenetxea JI. Brugada syndrome in a patient with accessory pathway. Europace 2002; 4:87-9</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">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.</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">8) Boveda S, Combes N, Albenque JP, et al. Brugada syndrome and supraventricular arrhythmiasArch Mal Coeur Vaiss. 2004; 97: 688-692.</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">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.</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial"><BR class="khtml-block-placeholder"></FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">10) Notarstefano P, Pratola C, Toselli T, et al Atrial fibrillation and recurrent ventricular fibrillation during hypokalemia in Brugada syndrome.</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">11) Sumiyoshi M, Nakazato Y, Tokano T, Sinus node dysfunction concomitant with Brugada syndrome. Circ J. 2005; 69:946-950.</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">All the best</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">Andrés Ricardo Pérez Riera</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Chief of Electro-Vectocardiology Sector of the Discipline of Cardiology,</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">ABC Faculty of Medicine (FMABC), Foundation of ABC (FUABC)</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">- Santo André - São Paulo - Brazil.</FONT></DIV><DIV style="margin-top: 0px; margin-right: 0px; margin-bottom: 0px; margin-left: 0px; "><FONT class="Apple-style-span" face="Arial">Rua Sebastião Afonso 885 - Zip Code: 044417-100- Jardim Miriam S.P Brazil-</FONT></DIV><DIV><BR class="khtml-block-placeholder"></DIV><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>