Heart Rhythm Congress, Birmingham, Monday 8th October 2018 · Early Repolarization in Athletes •...
Transcript of Heart Rhythm Congress, Birmingham, Monday 8th October 2018 · Early Repolarization in Athletes •...
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Andrew Grace
Royal Papworth Hospital - University of Cambridge
Consultant: Acutus Medical Inc., Bardy Diagnostics
Boston Scientific Inc. (member PSAB) and Founder, Electus Medical Inc.
Clinical Spectrum of Early Repolarization Syndrome
Heart Rhythm Congress, Birmingham, Monday 8th October 2018
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Normal Variant: Vagotonia (courtesy of Dr D Wilton)
The Electrocardiology of Coronary Artery Disease. Leo Schamroth. Blackwell. 1975
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Normal Variant: Vagotonia (courtesy of Dr D Wilton)
The Electrocardiology of Coronary Artery Disease. Leo Schamroth. Blackwell. 1975
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ST-Segment Elevation in Conditions other than Myocardial Infarction. Wang K et al. N Engl J Med 2003;349:2128-2135
Electrocardiograms Showing ST-Segment Elevation and Normal Variants
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ST-Segment Elevation in Conditions other than Myocardial Infarction. Wang K et al. N Engl J Med 2003;349:2128-2135
Electrocardiograms Showing ST-Segment Elevation and Normal Variants
90% young malesConcave ST
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ST-Segment Elevation in Conditions other than Myocardial Infarction. Wang K et al. N Engl J Med 2003;349:2128-2135
Electrocardiograms Showing ST-Segment Elevation and Normal Variants
ER patternNotch J point V4
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ST-Segment Elevation in Conditions other than Myocardial Infarction. Wang K et al. N Engl J Med 2003;349:2128-2135
Electrocardiograms Showing ST-Segment Elevation and Normal Variants
Normal VariantTerminal T-wave
InversionsST coved
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Journal of Electrocardiology 2000; 33:299-309
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Journal of Electrocardiology 2000; 33:299-309
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Sudden Cardiac Arrest Associated with Early Repolarization
N Engl J Med 2008;358:2016-2023
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• ER more prevalent in idiopathic VF survivors
(206) vs. controls (412)
• 31% vs. 5% (p<0.001)
• ER positive individuals more likely to have
further ICD therapy during follow-up (HR 2.1)
Sudden Cardiac Arrest Associated with Early Repolarization
N Engl J Med 2008;358:2016-2023
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Sudden Cardiac Arrest Associated with Early Repolarization
N Engl J Med 2008;358:2016-2023
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Sudden Cardiac Arrest Associated with Early Repolarization
N Engl J Med 2008;358:2016-2023
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Sudden Cardiac Arrest Associated with Early Repolarization
N Engl J Med 2008;358:2016-2023
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Sudden Cardiac Arrest Associated with Early Repolarization
N Engl J Med 2008;358:2016-2023
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TERMINOLOGY (2012)
Perez, Friday & Froelicher Am J Med 2012; 125:843-844
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Perez, Friday & Froelicher Am J Med 2012; 125:843-844
TERMINOLOGY (2012)
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Long-Outcome Associated with Early Repolarization
Tikkanen et al. N Engl J Med 2009;361:2529-37
• 10864 middle aged men f/u 30±11 years• ER pattern 630 (5.8%) inferior leads
Survival-free cardiac Survival-free arrhythmia
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Significance of associated ST segment
HR 0.89 (0.52-1.55)
ER – inf. ascending/upsloping
No ER
Tikkanen Circulation 2011; 123:2666-2673
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Significance of associated ST segment
HR 0.89 (0.52-1.55) HR 1.43 (1.05-1.94)
ER – inf. ascending/upsloping
ER – inf. Horizontal/descending
No ER
Tikkanen Circulation 2011; 123:2666-2673
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38 years, Asian, male, VF survivor
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Early Repolarization in Population
• Prevalence 6-13 % - decreases with age
• Benign Prognosis
– Inferior J-point elevation ≥ 0.2mV – HR 3.15 – only 0.3% pop
• Usual ER pattern and VF – absolute risk v. low
– Idiopathic VF <45 years – 3/100,000 p.a.
– ER pattern with J waves – 11/100,000 p.a.
Obeyesekere et al. Circulation 2013; 127: 1620-1629
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Prevalence of Early Repolarization (age/sex)
Noseworthy et al. J Am Coll Cardiol 2011; 57:2284-9
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HRS/EHRA/APHRS CONSENSUS STATEMENT
Europace 2013; 15:1389-1406
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HRS/EHRA/APHRS CONSENSUS STATEMENT
Europace 2013; 15:1389-1406
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HRS/EHRA/APHRS CONSENSUS STATEMENT
Europace 2013; 15:1389-1406
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HRS/EHRA/APHRS CONSENSUS STATEMENT
Europace 2013; 15:1389-1406
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Early Repolarization in Athletes
• Prevalence 20-50%
– Frequently associated with ST elevation and rapidly ascending ST segment
– More common in lateral leads
• Benign Prognosis (probably)
– Small cohorts have not shown increased risk
– Single case-control sudy showed association with athletic SCD
• Prevalence increases with period of training
– 37.2% to 52.7% after period of training1
• Association with structural athletic changes (probably)
– No association with LV remodeling1
– J waves associated with increased LVIDd, max. wall thickness and LV mass2
1Noseworthy et al. Circ. AE 2011; 2Quattrini et al. Heart Rhythm 2014
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ECG example – athletic appearance
29 years, Caucasian, male, soccer player, 44 bpm, ERP infero-lateral, LV+
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Obeyesekere Circulation 2013; 127: 1620-1629
Mechanisms: Hypothetical
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Obeyesekere Circulation 2013; 127: 1620-1629
Mechanisms: Hypothetical
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Mapping EP substrate in ERS (29 total, 17 malignant)
Zhang et al. JACC Clinical EP 2017; 127: 3:894-904
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PR interval – 50 loci identified by GWAS (N=92,000)
Van Setten et al. Nature Communications 2018; 127:9:2904
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DEEP PHENOTYPING INDIVIDUALS
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Conclusions
• ERS – here to stay – undoubted clinical signals
• Discernible patterns and stratified risk (clinical)
• ECG diagnosis – but ECG patterns e.g. PR interval familial anyway
• Need better phenotyping tools to provide platform for genetic studies