Brugada Patient and the Environment:Harmful Factors and Drugs

Juhani Junttila, MDInsitute of Clinical Medicine, University of Oulu, Oulu, Finland

Case

• 50 yrs male• Paroxysmal Afib• Treated with

flecainide• No family history of

SCD• No syncopal

episodes

Case

• Flecainide discontinued

• RBBB underlying morphology??

Induced Brugada ECG

• Patients with induced Brugada ECG by medication of by fever are at imminent risk for ventricular arrhythmias– In a case series of 47 patients with induced

Brugada ECG 51% developed ventricular arrhythmias

• Most cases had ventricular arrhythmias during fever or during anesthesia

Junttila MJ et al. Circulation 2008

Ion channel effects

IKr

IKs

Ito

INa

ICa

INa

Ito

Current decay for WT (squares) and Thr1620Met (circles) at 22°C (▪, •) and 32°C (□, ○).

Dumaine R et al. Circulation Research 1999;85:803-809

Fever

Fever

• 402 patients with fever (>38°) and 909 without

• 2% (n= 8) type I Brugada ECG in fever patients– 0.1% in controls, p< 0.001– Four had diagnostic finging of the syndrome after

fever• One Brugada ECG in repeated ECG• Three with positive ajmaline test

• All patients with Brugada ECG were asymptomatic and remained asymptomatic during 30mo of follow up

Adler A et al. Heart Rhythm. 2013

Fever

Sauna and Hot Tub

• Sauna: 30min in 80C° core temperature increase ~1C° in adults and ~2C° in children– Leppäluoto J. Ann Clin Res. 1988;20(4):240-3

• Hot tub: 15min of 40C° increased core body temperature by ~0.6C° – Allison TG, Miller TD, Squires RW et al. Mayo Clin Proc. 1993 Jan;68(1):19-25.

Sports

• Strenuous indurance training might be harmful – Increase in vagal tone?

• Leisure-time sport activity might not

be harmful• Patients with ICD should be

restricted from competetive sports?– Sports with low cardiovascular demand

should be allowedHeidbüchel H et al. Study Group on Sports Cardiology of the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2006

Other factors

• HypokalemiaAraki T et al. Circ J. 2003

• Glucose-insulin infusionNogami A et al. Pacing Clin Electrophysiol.

2003

Drugs –avoided

www.brugadadrugs.org Postema et al. Heart Rhythm 2009 and Postema et al. Europace 2013

Drugs –preferably avoided

www.brugadadrugs.org Postema et al. Heart Rhythm 2009 and Postema et al. Europace 2013

Drugs

Propofol infusion syndrome• Well known among anesthesiologists• Brugada ECG among first warning

signs • Lactic acidosis results in organ

failure

Conclusion

Antzelevitch C et al. Circulation 2005;111:659-670