INTRODUCTION: Risk stratification of asymptomatic patients with a Brugada type 1 ECG pattern remains an unresolved clinical conundrum. In contrast to provocative pharmacological testing in Brugada syndrome, there is limited data on the role of exercise stress testing as a risk stratification modality. The objective of this study was to evaluate the utility of exercise testing in asymptomatic patients with type 1 Brugada pattern to prognosticate major arrhythmic events (MAE) during follow-up. METHODS AND RESULTS: Treadmill exercise testing was conducted for 75 asymptomatic patients with type 1 Brugada pattern and for 88 healthy control subjects. The clinical end point of MAE was defined as the occurrence of sudden cardiac death (SCD) or resuscitated ventricular fibrillation (VF). During a follow-up of 77.9 ± 28.9 months, eight MAE occurred (five VF and three SCD). Multivariate Cox regression analysis showed that the following were independent predictors of MAE in asymptomatic patients with a type 1 Brugada pattern: increase in S wave upslope duration ratio >30% at peak exercise (HR 1.35, 95% CI 1.08-10.97, P = 0.023), augmentation of J point elevation in lead aVR >2 mm in late recovery (HR 1.88, 95% 1.21-15.67, P = 0.011), and delayed HR recovery (HR 1.14, 95% CI 1.06-18.22, P = 0.042). A high-risk cohort was identified by the final step-wise regression model with good accuracy (specificity = 98.4%, sensitivity = 62.5%) and discriminative power (AUC = 0.93, 95% CI 0.89-0.96, P = 0.002). Kaplan-Meier analysis revealed increasing MAE in subjects with one, two, or three predictors, respectively (log rank P < 0.001). CONCLUSIONS: Exercise testing in asymptomatic patients with type 1 Brugada pattern aids in identification of high-risk patients and provides a unique window of opportunity for early intervention.
Brugada Syndrome/diagnosis , Death, Sudden, Cardiac/etiology , Electrocardiography , Exercise Test , Ventricular Fibrillation/etiology , Adult , Area Under Curve , Asymptomatic Diseases , Brugada Syndrome/complications , Brugada Syndrome/mortality , Brugada Syndrome/physiopathology , Case-Control Studies , Disease-Free Survival , Female , Humans , Kaplan-Meier Estimate , Logistic Models , Male , Middle Aged , Predictive Value of Tests , ROC Curve , Risk Assessment , Risk Factors , Time Factors , Ventricular Fibrillation/diagnosis , Ventricular Fibrillation/mortality , Ventricular Fibrillation/physiopathology
BACKGROUND: Atrioventricular (AV) block is rare in Takotsubo cardiomyopathy (TC). CASE REPORT: A 66-year-old female presented with fatigue. Her electrocardiogram revealed 3:2 Mobitz Type II AV block, confirmed to be supra-Hisian by electrophysiological study. Echocardiogram and left ventricular angiogram showed moderate left ventricular dysfunction and apical ballooning, whereas coronary angiogram revealed mildly ectatic coronaries. At 2 weeks AV block persisted, needing permanent pacemaker implantation. At 1-month follow-up, she had normal ventricular function and no AV block. CONCLUSION: Delayed recovery of AV conduction is possible in TC, thus implying to wait for a longer period before implanting a pacemaker.
Bundle-Branch Block/diagnosis , Bundle-Branch Block/etiology , Electrocardiography/methods , Takotsubo Cardiomyopathy/complications , Takotsubo Cardiomyopathy/diagnosis , Aged , Diagnosis, Differential , Female , Humans , Rare Diseases/diagnosis , Rare Diseases/etiology
