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Quel bilan devant un aspect de repolarisation prcoce? Frdric Sacher Hopital Cardiologique du Haut Lvque LIRYC Institute, INSERM 1045 CHU de Bordeaux / Universit de Bordeaux France Disclosures Speaking honorarium: Biosense

  1. Quel bilan devant un aspect de repolarisation précoce? Frédéric Sacher Hopital Cardiologique du Haut Lévêque LIRYC Institute, INSERM 1045 CHU de Bordeaux / Université de Bordeaux France

  2. Disclosures – Speaking honorarium: Biosense Webster, Boston Scientific, Medtronic, Abbott, Microport, Boehringer Ingelheim, Bayer, Pfizer, BMS/Pfizer – Consulting fees: Abbott, Bayer Healthcare,

  3. Early Repolarization: Definition * Inferior Infero-lateral Slurring (late delta) or  distribution distribution notch at the end of QRS, * with J point>0.1mV (1mm) * in ≥ 2 leads * * Left precordial and/or  inferior and/or lateral ECG * leads (excluding V1-V3 for * Brugada/ARVD) * * * Haissaguerre M. et al. JICE 2007; Haissaguerre M et al. N Engl J Med 2008; Mac Farlane P. et al. JACC 2015

  4. ○ ○ ≥ ○ ≥ ○ ○ ○ ○ ≥ ○ ≥ ○ ○ QRS slurring QRS slurring w/o ST elevation with ST elevation ST segment elevation is ○ ○ ≥ ○ ≥ not sufficient for the diagnosis. ○ ○ QRS notching QRS notching J-wave/point elevation is w/o ST elevation with ST elevation necessary !! ○ ○ ≥ ○ ≥ ○ ○ ○ ○ ≥ ○ ≥ ○ ○ ○ ○ ≥ ○ ≥ ○ ○

  5. J wave elevation measurement Notch Slur D 1 D 2 Jo Jp Je MacFarlane PW et al. The ER Pattern: A Consensus Paper. JACC 2015

  6. Est-ce que tu validerais la repolarisation Demande précoce en inférieur? Patient totalement d’avis par mail asymptomatique et présentant un bloc de branche droit Pour quelle raison ne retiens-tu pas repo précoce ? Est-ce à cause du bloc de branche droit ?

  7. Evidences of the pathological relationship between J wave elevation and SCD 1- Prevalence of « early repolarisation » • 206 pts with resuscitated Idiopathic Ventricular Fibrillation in 24 tertiary care arrhythmia centres (No structural heart disease) • Matched with 412 healthy subjects (normal ECG and echo) for age, sex, ethnicity, sport. - 31% in pts with IVF vs 5% in the matched group (p=0.002) - 31% in pts with IVF vs 9% in controls (Rosso et al. JACC 08)

  8. Population  Ethnicity: No african or african/american people  Athletes: – None in Haissaguerre et al. NEJM 2008 – 121 In Rosso et al. JACC 2008 12% of J point elevation >0.1mV

  9. Definition 19 athletes with CA vs 365 control

  10. Evidences of the pathological relationship between J wave elevation and SCD 1- Prevalence of « early repolarisation » - 31% in pts with IVF vs 5% in the matched group (p=0.002) - 31% in pts with IVF vs 9% in controls (Rosso et al. JACC 08) 2- Amplitude of J point - 2.15±1.2mm in IVF vs 1.05±0.2mm in controls with « early repolarisation » 3- Dynamicity of J wave: Accentuation of the pattern at the time of Arrhythmias - Maximal J point elevation of 4.1 ±2mm (2 to 10 mm) 4- Correlation location J/ST and Arrhythmia origin

  12. What is the risk associated with ER ?  Early Repolarization Pattern Vs. Early Repolarization Syndrome  ER pattern is frequent in general population (1 to 9%)  Sudden Cardiac Death in young healthy adult is extremely rare  Data suggest: J-wave discovery in a young adult increase risk of SCD:  X 3

  13. What is the risk associated with ER ?  Early Repolarization Pattern Vs. Early Repolarization Syndrome  ER pattern is frequent in general population (1 to 9%)  Sudden Cardiac Death in young healthy adult is extremely rare  Data suggest: J-wave discovery in a young adult increase risk of SCD:  X 3  from 3.4:100,000 to 11:100,000 (Rosso et al. JACC 2008)

  14. Who is at risk?

  15. Clinical Features 1. Familial sudden cardiac death <45 yo 2. Previous aborted cardiac death 3. Presyncope or syncope ++ 39% of patients with cardiac arrest had a history of syncope • Follow-up of patients with Syncope and ER - Multicentric study (17centers) - 63 pts (33yo, 54males) - 37 with ILR or ICD - 3 recorded Polymorphic VT on ILR (mean f/u 7 months) Maury P et al. EUROPACE 2011 ; Le Bloa et al. HRS 2012

  16. ECG N Engl J Med. 2009 Nov 16  J-point elevation in inferior leads – >0.1mV (5.8%)  RR cardiac death: 1.30 (CI:1.05 – 1.61, p=0.02) – >0.2 mV (0,33%)  RR cardiac death: 3.03 (CI 1.88-4.90, p=0.001)  RR arrhythmic death: 2.99 (CI 1.49-6.03, p=0.005) Stronger predictors than QT interval and LVH

  17. Dynamic Entity 7h 15h H 34yr, convulsions while sleeping. 2 ECGs the same day

  18. Vasalva maneuvers Gourraud JB et al. JACC 2013

  19. ECG Mean J wave amplitudes and VF recurrence Inferior J waves High lat. J waves Lateral J waves Global J waves P=0.004 P=0.12 P=0.24 P=0.002 Boxplots show median, lower/upper quartiles, minimum, maximum and outliers. Y axis shows mV in all graphs Roten, Derval et al. Cardiostim 2012

  20. J-wave morphology  Notch morphology more prevalent in IVF population especially in left precordial  44% Vs. 8% p=.001  Small case-control study and one population study (Rollin et al. Am J Cardiol 2012)  Not reported in larger study

  21. Horizontal/descending ST segment Ascending ST segment  benign outcome Horizontal/descending ST segment  poorer outcome Tikkanen J et al. Circulation 2011 (Risk of arrhythmic death: HR 3.14 – 1.56-6.30)) Rosso R et al. Heart Rhythm 2011 (Risk of idiopathic VF OR: 13.8 (CI 5.1-37.2)) Rollin A et al. Am J Cardiol 2012 ( Risk of cardiovascular mortality HR: 8.75 (CI 3.48-22))

  22. EPS & Early Repolarization?

  23. No Pharmacological test to depict malignant Early Repolarization – No change : verapamil , epinephrine, ATP, cibenzoline, pilsicainide, Ca – Slight accentuation : bradycardia, Betablockers Roten, derval et al. Heart rhythm 2012; 9:232-9 – Decrease or no change: Ajmaline, flecainide – Decrease with Exercise/Isoproterenol and under Quinidine*. Both are powerful treatments for arrhythmic storms or multiple VF. Roten, derval et al. Heart rhythm

  24. Implantable Cardioverter Defibrillator Antzelevitch et al. J WAVE SYNDROMES EXPERT CONSENSUS CONFERENCE: Emerging Concepts & Gaps in Knowledge. Heart Rhythm 2016

  25. 32 yo asymptomatic male systematic ECG

  26. 35 yo asymptomatic male systematic ECG Vasalva maneuvers

  27. Valsalva maneuver

  28. Valsalva maneuver: end

  29. Is it a benign ECG? 36 yo female, no familial history, no medical history

  30. Bernard A et al. JICE 2009

  31. Is it a benign ECG? 10 yo girl with syncope Brother died suddenly at 17 One month after quinidine start Courtesy of Vincent Probst( CHU de Nantes, France)

  32. Should this patient be left alone? 34 yo asymptomatic patients His brother died suddenly 6 month ago (during sleep) Courtesy of Olivier Piot ( CCN, France)

  33. Conclusions  A small subset of patients with ER will have VF: – RISK STRATIFICATION: resuscitated SCD , syncope and major J wave elevation/horizontal ST segment .  If asymptomatic, no familial history of SD and standard ER pattern (1mm J wave elevation)  NOTHING  Otherwise: – ECG with Vasalva maneuvers, TTE, Holter ECG, +/- Stress test and refer to expert cardiologist – In case of severe history of familial SCD or atypical lightheadednes --- > Implantable loop recorder

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