Evaluation of a new treadmill exercise protocol to unmask type 1 Brugada electrocardiographic pattern: can we improve diagnostic yield?

AIMS: High precordial leads (HPL) on the resting electrocardiogram (ECG) are widely used to improve diagnostic detection of type 1 Brugada ECG pattern (Br1ECGp). A parasympathetic activation marks the initial recovery phase of treadmill stress testing (TET), and this can be useful for detecting the typical ECG pattern. Our study aimed to evaluate the role of a new HPL-treadmill exercise testing (TET) protocol in detecting Br1ECGp fluctuation compared to resting HPL-ECG. METHODS AND RESULTS: 74 out of 163 patients of a Brugada syndrome (BrS) Brazilian cohort (GenBra Registry) underwent exercise testing with HPL-TET protocol. Precordial leads were displayed in strategic positions in the right and left parasternal spaces. The step-by-step analysis included ECG classification (as presence or absence of Br1ECGp) in standard vs. HPL leads placement in the following sequences: resting phase, maximal exercise, and the passive recovery phase (including 'quick lay down'). For heart rate recovery (HRR) measurements and comparisons, a Student's t-test was applied. McNemar tests compared the detection of Br1ECGp. The significance level was defined as P < 0.05. Fifty-seven patients (57/74; 77%) were male, the mean age was 49.0 ± 14, 78.4% had spontaneous BrS, and the mean Shanghai score was 4.5. The HPL-TET protocol increased Br1ECGp detection by 32.4% against resting HPL-ECG (52.7% vs. 20.3%, P = 0.001) alone. CONCLUSION: Stress testing using HPL with the passive recovery phase in the supine position offers an opportunity to unmask the type 1 Br1ECGp, which could increase the diagnostic yield in this population.

Effect of psychotherapy on recurrence of events and quality of life in patients with vasovagal syncope.

Emotional distress is related to recurrence of syncope compromising patient's quality of life (QoL). The aim of this study was to determine if weekly sessions of psychotherapy reduce recurrence of events and improve QoL by SF-36 among patients with refractory vasovagal syncope. A randomised controlled pilot trial including 10 patients with recurrent vasovagal syncope and positive tilt table test was conducted. Known cardiac disease and ongoing psychotherapeutic interventions were the main exclusion criteria. All patients received standard of care treatment. Additionally, after randomisation, half of the patients underwent weekly sessions of psychotherapy for 12 months. Analysis of recurrence of events and QoL showed no significant change in the control group but, in the intervention group, there was a significant reduction in the rate of near-syncope episodes per month (5.7 ± 1.4 × 1.7 ± 1.0; P < 0.01), syncope in 1 year (4.6 ± 0.9 × 1.0 ± 0.7; P < 0.01) and a significant improvement in the overall assessment of QoL (44.1 ± 10.0 vs. 70.3 ± 10.3, P < 0.01). In conclusion, patients with refractory vasovagal syncope undergoing regular psychotherapeutic intervention had less recurrence of events and improved their quality of life in 1 year.Trial Registration: ClinicalTrials.gov number, NCT04252729.

Cost-Effectiveness and Cost-Utility Analyses of Dabigatran Compared with Warfarin in Patients with Nonvalvular Atrial Fibrillation and Risk Factors for Stroke and Systemic Embolism within Brazilian Private and Public Health Care Systems Perspectives.

OBJECTIVE: To analyze the cost-effectiveness and cost-utility of dabigatran compared with warfarin in patients with nonvalvular atrial fibrillation with moderate to high risk of ischemic stroke or systemic embolism and eligible for treatment with anticoagulants. METHODS: Markov-based economic analysis was performed to estimate treatment costs and outcomes. Epidemiological and efficacy data were determined after a critical revision of the medical literature. Unit costs were taken from Brazilian official databases. Only direct medical costs were covered. Costs and benefits were discounted at a rate of 5% per year. Outcomes were expressed as life-year (LY) and quality-adjusted life-year (QALY). RESULTS: Dabigatran use is cost-effective in terms of LY and QALY considering a willingness-to-pay threshold of 3 times gross domestic product per capita of 2010 (Brazilian real 57,048/US $24,275.74) per LY and QALY saved in both analyzed perspectives (private and public health care systems). CONCLUSIONS: Dabigatran use improves patient survival and quality of life compared with warfarin. This represents the best therapeutic option in terms of cost and effectiveness in the prevention of ischemic stroke and systemic embolism in patients with nonvalvular atrial fibrillation.