Long-term prognosis of patients with Brugada syndrome and an implanted cardioverter-defibrillator | Revista Portuguesa de Cardiologia (English edition)

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ECG: electrocardiogram; EPS: electrophysiological study; SCD: sudden cardiac death." ] ] ] "textoCompleto" => "IntroductionBrugada syndrome is an inherited arrhythmogenic heart disease characterized by an increased risk of sudden cardiac death (SCD) due to ventricular tachycardia (VT)/ventricular fibrillation (VF). The syndrome accounts for approximately 4% of all SCD and up to 20% of sudden deaths in patients with structurally normal hearts.<a class="elsevierStyleCrossRef" href="#bib0150">1</a> Several series have demonstrated a significant recurrence rate of malignant arrhythmic events in high-risk patients, suggesting that implantable cardioverter-defibrillator (ICD) implantation is beneficial.<a class="elsevierStyleCrossRefs" href="#bib0155">2–4</a> Risk stratification is thus a central step in assessment of patients with Brugada syndrome, allowing for the identification of individuals at higher risk of arrhythmic events who would benefit from an ICD. The problem is that there is still controversy as to how to stratify these patients and doubts as to which patients should receive a prophylactic ICD.The most common variables associated with a higher risk of arrhythmic events in Brugada syndrome patients are aborted SCD, history of syncope and spontaneous type 1 electrocardiographic (ECG) pattern, but the role of the electrophysiological study (EPS) is not well established due to contradictory results in the published literature.<a class="elsevierStyleCrossRefs" href="#bib0165">4,5</a>There is consensus for the implantation of an ICD in cardiac arrest survivors, and there is general agreement that patients with a spontaneous ECG pattern and a history of syncope or documented VT that has not resulted in SCD should receive an ICD.<a class="elsevierStyleCrossRefs" href="#bib0175">6–8</a> At the other end of the spectrum, in low-risk patients (asymptomatic with type 1 ECG only after pharmacological provocation), clinical follow-up is also generally accepted.<a class="elsevierStyleCrossRefs" href="#bib0175">6–8</a> However, in patients with syncope and pharmacologically induced type 1 ECG or asymptomatic patients with spontaneous type 1 ECG, whether to implant a prophylactic ICD is currently a major dilemma.In this study, the main objectives were to assess the long-term prognosis of Brugada syndrome patients with an ICD implanted for primary or secondary prevention of SCD and to identify independent predictors of appropriate shocks during follow-up.MethodsPopulationFifty-five consecutive patients with Brugada syndrome were assessed retrospectively in a single tertiary center between April 2002 and October 2012. A diagnosis of Brugada syndrome was established after an episode of aborted SCD, during investigation of syncope, in asymptomatic patients during routine clinical examination with typical ECG patterns, or during family screening.Diagnosis, clinical assessment and electrophysiological studyThe following clinical data of interest were recorded: demographic characteristics (gender, age and race); clinical presentation (aborted SCD and syncope); and family history of SCD and nonsustained ventricular tachycardia (NSVT) during follow-up. ECGs were reviewed and classified by two physicians according to the consensus report of current electrocardiographic criteria for diagnosis of Brugada pattern.<a class="elsevierStyleCrossRef" href="#bib0190">9</a> Routine examinations included transthoracic echocardiogram for exclusion of structural cardiac disease and laboratory tests for exclusion of metabolic and electrolyte abnormalities. Intravenous flecainide, a sodium-channel-blocking agent, was used for provocative pharmacological tests (2 mg/kg bodyweight over 10 min with a maximum dose of 150 mg). EPS was performed with two drive cycles (600 and 400 ms, S1) and a maximum of three ventricular extrastimuli (S2, S3 and S4) delivered from two different ventricular sites (right ventricular apex and right ventricular outflow tract), unless VF or sustained VT (lasting >30 s), causing syncope, or requiring intervention for termination, was elicited in a previous step. Minimum coupling interval was 200 ms for S2 to S4. A positive EPS was defined as induced VF, sustained polymorphic VT or polymorphic syncopal VT requiring direct current shock.Implantable cardioverter-defibrillator implantation and follow-upICDs were implanted according to the criteria recommended in the second consensus report on Brugada syndrome.<a class="elsevierStyleCrossRef" href="#bib0175">6</a> Implantation was performed with a transvenous system in all patients, through the cephalic or left subclavian vein at the operator's discretion. It is our routine protocol to program a single VF zone with a detection rate of 180–200 bpm and backup pacing at a rate of 45 bpm for these patients. Appropriate shocks were defined as shocks delivered for VT or VF; inappropriate shocks were defined as shocks delivered in the absence of ventricular arrhythmia. The main endpoint assessed during a mean follow-up of 74±40 months (>5 years in 72% of cases) was the occurrence of appropriate shocks.Statistical analysisContinuous variables were expressed as mean ± standard deviation. Discrete variables were expressed as frequencies and percentages. Statistical comparisons of baseline characteristics and outcomes were performed using the chi-square test or Fisher's exact test, as appropriate, for categorical variables and the Student's t test for continuous variables. Corrected risk estimates were performed using a Cox proportional hazard regression model including the following variables: spontaneous type 1 ECG pattern, history of syncope, aborted SCD and NSVT during follow-up. For this analysis the time to first appropriate shock was considered. Receiver operating characteristic (ROC) analysis was performed with determination of the area under the curve (AUC) and respective specificity, sensitivity, positive and negative predictive values. Two-tailed tests of significance are reported. For all comparisons, a p value of <0.05 was considered statistically significant. When appropriate, 95% confidence intervals (CI) were calculated. The statistical analysis was performed with SPSS version 19.0 (SPSS Inc., Chicago, IL, USA).ResultsPatient characteristicsOf the 55 patients with Brugada syndrome included in the present analysis, 36 (65.5%; mean age 41.7±13.8 years; 81.8% male) underwent ICD implantation. The baseline characteristics of these patients are depicted in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Briefly, 19 (52.8%) patients were asymptomatic, 11 (30.6%) had a previous history of syncope (with a possible arrhythmic cause suspected in eight patients), six (16.7%) had aborted SCD and 14 (38.9%) had a family history of SCD. Spontaneous type 1 ECG pattern was present in 25 (69.4%) patients. EPS was performed in 26 (72.2%) patients, with positive results in 22 (84.6%). Provocative testing with flecainide was performed in 14 (38.9%) patients. Indications for ICD implantation are represented in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Outcome and follow-up analysisDuring a mean follow-up of 74±40 months (>5 years in 72% of cases), seven patients experienced appropriate shocks, corresponding to an incidence of 19.4% and an annual event rate of 2.8%. Four patients had arrhythmic storm (successfully treated with quinidine). Median time to the first appropriate shock was 17 months, all events occurring between 3 and 51 months after ICD implantation. With regard to clinical presentation, the rate of appropriate shocks was significantly lower in asymptomatic patients than in those with a history of syncope and aborted SCD: 10.5%, 18.2% and 66.7%, respectively (p=0.007) (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The majority of patients with appropriate shocks were men, with aborted SCD and spontaneous type 1 ECG pattern (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). Comparing patients with and without appropriate shocks, the first group had a statistically significant higher prevalence of aborted SCD (54.1% vs. 6.9%, p=0.008) and NSVT (57.1% vs. 10.3%, p=0.016) during follow-up. Spontaneous type 1 ECG pattern, family history of SCD, syncope and positive EPS did not present a statistically significant association with appropriate shocks (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In the two patients with syncope at presentation and appropriate shocks during follow-up, an arrhythmic cause for syncope was suspected. Multivariate analysis adjusted for statistically significant characteristics in univariate analysis (aborted SCD and NSVT during follow-up) and for spontaneous type 1 ECG pattern and history of syncope revealed independent predictors of appropriate shocks to be aborted SCD (hazard ratio [HR] 7.87, 95% CI 1.27–49.6; p=0.027) and NSVT during follow-up (HR 6.73, 95% CI 1.27–35.7; p=0.025). By ROC curve analysis, aborted SCD had moderate discriminatory power to predict the occurrence of appropriate shocks (AUC=0.751), with sensitivity and specificity of 57% and 93%, respectively (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). None of the patients died during follow-up. In terms of ICD-related complications, eight (22.2%) patients had inappropriate shocks during the follow-up period, mainly due to sinus tachycardia (five patients), mainly managed by increasing ICD thresholds or by beta-blocker therapy. One patient had documented lead infection and underwent device replacement and another had a lead fracture.<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>During the mean follow-up of 69±31 months, the 19 patients without ICD implantation were alive, and only one underwent ICD implantation, without occurrence of appropriate shocks.DiscussionBrugada syndrome is an arrhythmogenic disease associated with a high risk of SCD in young individuals with structurally normal hearts, and is classically characterized by an ECG phenotype of right bundle branch block and ST-segment elevation in the right precordial leads.<a class="elsevierStyleCrossRefs" href="#bib0150">1,9</a> The prevalence of the syndrome is difficult to estimate since ECG findings can be dynamic and/or concealed, and there are potentially endemic regions for the genetic alterations associated with this entity (mutations in the SCN5A sodium channel gene). Its prevalence is estimated at approximately 5/10 000 individuals, with a higher prevalence in Asia.<a class="elsevierStyleCrossRefs" href="#bib0195">10–13</a>Risk stratification of SCD is essential to the management of patients with Brugada syndrome. The objective is to identify patients at higher risk of SCD who may benefit from ICD implantation, the only measure with proven survival benefit in these patients.<a class="elsevierStyleCrossRef" href="#bib0185">8</a> A substantial part of the evidence for the advantages of an ICD comes from the results of the DEBUT trial.<a class="elsevierStyleCrossRef" href="#bib0215">14</a> No pharmacological therapy has shown to improve survival in Brugada syndrome patients, but class IA antiarrhythmic drugs, particularly quinidine, which inhibit the potassium transient outward current of the action potential, may be useful in refractory cases.<a class="elsevierStyleCrossRef" href="#bib0220">15</a>In the present study, performed in patients with Brugada syndrome who received an ICD for primary or secondary prevention, the long-term (mean follow-up of 6.2 years) annual event rate of potentially life-threatening ventricular arrhythmias was 2.8%/year. The rate of appropriate ICD shocks was similar to results previously published by Rosso et al.<a class="elsevierStyleCrossRef" href="#bib0225">16</a> and Sacher et al.,<a class="elsevierStyleCrossRef" href="#bib0230">17</a> despite the longer follow-up in our analysis.Several characteristics have been described as predictors of the occurrence of arrhythmic events in Brugada syndrome patients. Aborted SCD, history of syncope, spontaneous type 1 ECG pattern and positive EPS are associated with increased risk.<a class="elsevierStyleCrossRefs" href="#bib0155">2,18</a> However, distribution of these characteristics among different published studies is not homogeneous. In the FINGER registry,<a class="elsevierStyleCrossRef" href="#bib0240">19</a> during a mean follow-up of 32 months, cardiac events (appropriate shocks or SCD) were recorded in 5% of Brugada patients. Independent predictors of the event were aborted SCD, syncope and spontaneous type 1 ECG. In fact, a history of syncope and aborted SCD are the most common clinical manifestations in Brugada syndrome patients, predominantly manifested in men during the third and fourth decades of life.<a class="elsevierStyleCrossRef" href="#bib0220">15</a> Nevertheless, a significant number of patients with Brugada syndrome are asymptomatic at the time of diagnosis. These patients have a more favorable long-term prognosis compared with those with symptomatic presentation (e.g. aborted SCD, syncope or symptomatic VT).<a class="elsevierStyleCrossRef" href="#bib0245">20</a>When analyzed in a multivariate model, aborted SCD and NSVT during follow-up were the only independent predictors of appropriate shocks in our analysis. Aborted SCD had moderate discriminatory power to predict this outcome. It is important to recall that an appropriate shock is not synonymous with SCD. Although a proven relation between aborted SCD and the risk of arrhythmic events in Brugada syndrome patients has been frequently reported, an independent association of NSVT with appropriate shocks during follow-up has also been described.<a class="elsevierStyleCrossRef" href="#bib0250">21</a> However, it should be borne in mind that NSVT episodes saved in the ICD data log are dependent on the heart rate and duration in the device programming.The association between syncope and the occurrence of appropriate shocks remains somewhat controversial.<a class="elsevierStyleCrossRefs" href="#bib0255">22,23</a> In our study, syncope was the major symptom at diagnosis, mainly of arrhythmic origin, but was not significantly associated with the occurrence of appropriate shocks at long-term follow-up. Similarly to our results, in a study by Sarkozy et al.,<a class="elsevierStyleCrossRef" href="#bib0265">24</a> syncope was not a predictor of arrhythmic events after prophylactic ICD implantation. Unfortunately, sometimes it is not easy to differentiate the origin of syncope between benign (reflex) or potentially fatal (VT). This difficulty suggests that patients with benign syncope may have comprised a significant part of our syncopal population, which may have distorted the results. In another analysis of 203 patients with Brugada syndrome,<a class="elsevierStyleCrossRef" href="#bib0270">25</a> the prevalence of syncope was 28% and in many cases a cardiac etiology was considered unlikely. The follow-up of these patients showed that long-term arrhythmic events occurred only in patients with syncope of cardiac origin. Similarly, in our study events occurred only in patients with possible arrhythmic syncope.Type 1 ECG pattern and inducibility during EPS were not predictors of appropriate shocks. The role of EPS in risk stratification and management of Brugada syndrome patients is not well established, with published data revealing conflicting results. Brugada et al.<a class="elsevierStyleCrossRef" href="#bib0170">5</a> suggest that VT/VF induction in asymptomatic patients is significantly correlated with an increased risk of SCD; on the other hand, Priori et al.<a class="elsevierStyleCrossRef" href="#bib0165">4</a> suggest that EPS does not add significant value to risk stratification in either symptomatic or asymptomatic patients. These discrepancies may be explained by the differences in baseline characteristics of the study populations and the different stimulation protocols. In fact, it is known that programmed stimulation induces VF in 6–9% of apparently healthy individuals, representing false positives, particularly when more aggressive protocols are used.<a class="elsevierStyleCrossRefs" href="#bib0275">26,27</a> Paul et al.<a class="elsevierStyleCrossRef" href="#bib0285">28</a> performed a meta-analysis to assess the role of programmed ventricular stimulation in patients with Brugada syndrome, and showed that EPS did not have a significant role in predicting arrhythmic events during follow-up.In our study a family history of SCD in first-degree relatives was not associated with an increased risk of arrhythmic events during follow-up. This finding is in agreement with the results of several previously published studies.<a class="elsevierStyleCrossRefs" href="#bib0230">17,19,24</a> A positive provocative pharmacological test with flecainide also failed to identify patients with increased risk of appropriate shocks, as described in the PRELUDE Registry.<a class="elsevierStyleCrossRef" href="#bib0235">18</a>Our results support both the importance of ICD implantation in SCD survivors and the current non-invasive strategy of close follow-up, without device implantation, in asymptomatic patients. In patients with syncope, discrepancies from previous results highlight the need for better discrimination of the nature of syncope (arrhythmic vs. reflex).Only two patients had severe complications associated with ICD implantation (infection and lead fracture) requiring device replacement, while eight patients had inappropriate shocks during follow-up. Given the young age and active lifestyle of our patients, many engaging in regular sports, it is not surprising that the leading cause of inappropriate shocks was sinus tachycardia.<a class="elsevierStyleCrossRefs" href="#bib0230">17,19</a> The rate of ICD complications exceeding the rate of arrhythmic events during follow-up has been previously reported,<a class="elsevierStyleCrossRefs" href="#bib0250">21,29</a> highlighting the importance of an accurate risk stratification scheme. Inappropriate patient selection for ICD implantation may result in a considerable increase in healthcare costs and may expose asymptomatic individuals to ICD-related complications.<a class="elsevierStyleCrossRef" href="#bib0230">17</a>The present study has some limitations. It is retrospective and the small number of patients and the low event rate during follow-up make it difficult to draw any definitive conclusions regarding predictors of long-term outcome. Some ventricular tachyarrhythmias may terminate spontaneously, depending on how the device is programmed.ConclusionsLong-term prognostic analysis of patients with Brugada syndrome and an ICD implanted for primary or secondary prevention revealed an annual event rate of potentially life-threatening ventricular arrhythmias of 2.8%/year. Aborted SCD and NSVT during follow-up were independent predictors of the occurrence of appropriate shocks, whereas syncope, type 1 ECG pattern, EPS and family history of SCD were not associated with a higher rate of events in this population. The number of patients with inappropriate shocks was similar to the number of patients with appropriate shocks, and two patients had serious ICD-related complications. Risk stratification of patients with Brugada syndrome remains controversial and the risk/benefit ratio of this therapy should be taken into account.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that no patient data appear in this article.Right to privacy and informed consentThe authors declare that no patient data appear in this article.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres525244" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods and Results" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec545482" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres525245" "titulo" => "Resumo" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Métodos e resultados" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec545483" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis, clinical assessment and electrophysiological study" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Implantable cardioverter-defibrillator implantation and follow-up" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Patient characteristics" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Outcome and follow-up analysis" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0060" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-01-28" "fechaAceptado" => "2014-12-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec545482" "palabras" => array:6 [ 0 => "Brugada syndrome" 1 => "Implantable cardioverter-defibrillator" 2 => "Prognosis" 3 => "Syncope" 4 => "Sudden cardiac death" 5 => "Appropriate shocks" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec545483" "palabras" => array:6 [ 0 => "Síndrome de Brugada" 1 => "Cardiodesfibrilhador" 2 => "Prognóstico" 3 => "Síncope" 4 => "Morte súbita" 5 => "Choques apropriados" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionRisk stratification of Brugada syndrome (BrS) remains controversial and recommendations for an implantable cardioverter-defibrillator (ICD) are not well established. The objective of this study was to assess the long-term prognosis of BrS patients with an ICD. Methods and ResultsOf 55 consecutive patients with BrS assessed between April 2002 and October 2012, 36 (mean age 41.7±13.8 years; 81.8% male) underwent ICD implantation. Nineteen (52.8%) were asymptomatic, 11 (30.6%) had previous history of syncope (arrhythmic cause suspected in eight) and six (16.7%) had aborted sudden cardiac death (SCD). Spontaneous type 1 electrocardiographic (ECG) pattern was present in 25 (69.4%) patients and electrophysiological study (EPS), performed in 26 (72.2%), was positive in 22 (84.6%). During a mean follow-up of 74±40 months (>5 years in 72% of cases), seven (19.4%) patients had appropriate shocks (annual event rate 2.8%). These patients most frequently had aborted SCD (54.1% vs. 6.9%; p=0.008) and nonsustained ventricular tachycardia (57.1% vs. 10.3%; p=0.016) during follow-up. Spontaneous type 1 ECG pattern, syncope and positive EPS were not significantly associated with appropriate shocks. Multivariate analysis revealed that aborted SCD was an independent predictor of appropriate shocks (HR 8.07, 95% CI 1.58–41.2; p=0.012). ROC curve analysis demonstrated that aborted SCD had moderate discriminatory power to predict appropriate shocks (AUC 0.751), with sensitivity of 57% and specificity of 93%. In terms of ICD-related complications, eight (22.2%) patients had inappropriate shocks during the follow-up period, mainly due to sinus tachycardia (five patients); one patient had lead infection and another had a lead fracture. ConclusionIn this population of BrS patients with ICD, the long-term rate of appropriate shocks was 2.8%/year. Aborted SCD was associated with a higher risk of appropriate shocks, whereas syncope and spontaneous type I ECG pattern did not predict this event." "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods and Results" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "IntroduçãoA estratificação de risco na síndrome de Brugada (SB) permanece controversa e as recomendações para cardiodesfibrilhador (CDI) não estão bem definidas. O objetivo deste estudo foi avaliar o prognóstico a longo prazo de doentes com SB e CDI implantado. Métodos e resultadosDe 55 doentes consecutivos com SB avaliados entre abril/2002-outubro/2012, 36 (idade média 41,7±13,8 anos; 81,8% homens) implantaram CDI. Dezanove (52,8%) eram assintomáticos, 11 (30,6%) tinham história de síncope (oito com suspeita de causa arrítmica) e seis (16,7%) foram reanimados de morte súbita (MS). O eletrocardiograma (ECG) com padrão tipo 1 espontâneo estava presente em 25 (69,4%) doentes e foi realizado estudo eletrofisiológico (EEF) em 26 (72,2%), sendo positivo em 22 (84,6%). Durante o período de seguimento médio de 74±40 meses (>5 anos em 72% dos casos), sete (19,4%) doentes tiveram choques apropriados (incidência anual 2,8%). Estes doentes tinham mais frequentemente história de MS abortada (54,1 versus 6,9%; p=0,008) e taquicardia não mantida (57,1 versus 10,3%; p=0,016) durante o seguimento. Padrão ECG tipo 1 espontâneo, síncope e EEF positivo não se associaram significativamente à ocorrência de choques apropriados. Em análise multivariada a MS abortada manteve-se preditor independente de choques apropriados (HR 8,07 IC95% 1,58-41,2; p=0,012). Em análise de curvas ROC a MS abortada apresentou um poder discriminatório moderado para predizer choques apropriados (AUC 0,751) – sensibilidade 57% e especificidade 93%. Relativamente às complicações relacionadas com o CDI, oito (22,2%) doentes tiveram choques inapropriados durante o período de seguimento, sobretudo por taquicardia sinusal (cinco doentes), um infeção de elétrodo e outro fratura de elétrodo. ConclusãoNa população estudada de doentes com SB e CDI implantado a incidência de choques apropriados foi 2,8%/ano. A MS abortada associou-se a um maior risco de choques apropriados, enquanto a síncope e o padrão de ECG tipo 1 espontâneo não foram preditores deste evento." "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Métodos e resultados" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusão" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1854 "Ancho" => 2667 "Tamanyo" => 230947 ] ] "descripcion" => array:1 [ "en" => "Indications for ICD implantation in the study population. ECG: electrocardiogram; EPS: electrophysiological study; ICD: implantable cardioverter-defibrillator; SCD: sudden cardiac death." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1410 "Ancho" => 1313 "Tamanyo" => 113469 ] ] "descripcion" => array:1 [ "en" => "Survival analysis comparing clinical presentation: aborted SCD vs. syncope vs. asymptomatic patients (p=0.007). SCD: sudden cardiac death." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1243 "Ancho" => 2667 "Tamanyo" => 190445 ] ] "descripcion" => array:1 [ "en" => "Characteristics of patients with appropriate shocks during follow-up (gray squares). ECG: electrocardiogram; EPS: electrophysiological study; SCD: sudden cardiac death." ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ECG: electrocardiogram; EPS: electrophysiological study; SCD: sudden cardiac death." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Demographic</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.7±12.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (83.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Caucasian \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 (97.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Clinical</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Aborted SCD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Syncope \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (30.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (52.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Family history of SCD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (38.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Electrocardiographic</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Type 1 ECG pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (69.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Type 2 ECG pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (22.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Without typical ECG pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (8.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Diagnostic workup and therapeutic approach</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">EPS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (72.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Positive EPS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (84.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Provocative test with flecainide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (38.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab847208.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of patients with ICD (n=36)." ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "ECG: electrocardiogram; EPS: electrophysiological study; NSVT: non-sustained ventricular tachycardia; SCD: sudden cardiac death." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Shocks (n=7) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No shocks (n=29) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (85.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (82.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Aborted SCD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (57.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (6.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.008 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Syncope \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (31.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Family history of SCD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (28.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (41.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.681 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Spontaneous type 1 ECG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (71.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (69.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Positive EPS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (42.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (65.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.394 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">NSVT (follow-up) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (57.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (10.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.016 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab847207.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Comparison of patients according to the occurrence of appropriate shocks." ] ] 5 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "AUC: area under the curve; ECG: electrocardiogram; EPS: electrophysiological study; PPV: positive predictive value; NPV: negative predictive value; NSVT: non-sustained ventricular tachycardia; SCD: sudden cardiac death." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AUC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sensitivity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Specificity \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PPV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NPV \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Aborted SCD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.751 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.514–0.988 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.041 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Syncope \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.488 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.248–0.728 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.920 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Type 1 ECG pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.512 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.272–0.752 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.920 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Positive EPS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.387 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.149–0.625 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.358 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">NSVT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.734 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.497–0.971 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.058 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab847209.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Predictive value for appropriate shocks of different characteristics." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:29 [ 0 => array:3 [ "identificador" => "bib0150" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. A multicenter report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Brugada" 1 => "J. Brugada" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "1992" "volumen" => "20" "paginaInicial" => "1391" "paginaFinal" => "1396" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1309182" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0155" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Determinants of sudden cardiac death in individuals with the electrocardiographic pattern of Brugada syndrome and no previous cardiac arrest" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Brugada" 1 => "R. Brugada" 2 => "P. Brugada" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/01.CIR.0000104568.13957.4F" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2003" "volumen" => "108" "paginaInicial" => "3092" "paginaFinal" => "3096" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14623800" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0160" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pharmacological and device approach to therapy of inherited cardiac diseases associated with cardiac arrhythmias and sudden death" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Brugada" 1 => "R. Brugada" 2 => "P. 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Long-term prognosis of patients with Brugada syndrome and an implanted cardioverter-defibrillator

Hélder Doresa,

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heldores@hotmail.com

Corresponding author.

, Katya Reis Santosb, Pedro Adragãoa, Francisco Moscoso Costaa, Pedro Galvão Santosa, Pedro Carmoa, Diogo Cavacoa, Francisco Bello Morgadoa, Miguel Mendesa

a Serviço de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal

b Centro Cardiovascular, Hospital da Luz, Lisboa, Portugal

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in low-risk patients &#40;asymptomatic with type 1 ECG only after pharmacological provocation&#41;&#44; clinical follow-up is also generally accepted&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#8211;8</span></a> However&#44; in patients with syncope and pharmacologically induced type 1 ECG or asymptomatic patients with spontaneous type 1 ECG&#44; whether to implant a prophylactic ICD is currently a major dilemma&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this study&#44; the main objectives were to assess the long-term prognosis of Brugada syndrome patients with an ICD implanted for primary or secondary prevention of SCD and to identify independent predictors of appropriate shocks during follow-up&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Population</span><p id="par0025" class="elsevierStylePara elsevierViewall">Fifty-five consecutive patients with Brugada syndrome were assessed retrospectively in a single tertiary center between April 2002 and October 2012&#46; A diagnosis of Brugada syndrome was established after an episode of aborted SCD&#44; during investigation of syncope&#44; in asymptomatic patients during routine clinical examination with typical ECG patterns&#44; or during family screening&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diagnosis&#44; clinical assessment and electrophysiological study</span><p id="par0030" class="elsevierStylePara elsevierViewall">The following clinical data of interest were recorded&#58; demographic characteristics &#40;gender&#44; age and race&#41;&#59; clinical presentation &#40;aborted SCD and syncope&#41;&#59; and family history of SCD and nonsustained ventricular tachycardia &#40;NSVT&#41; during follow-up&#46; ECGs were reviewed and classified by two physicians according to the consensus report of current electrocardiographic criteria for diagnosis of Brugada pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> Routine examinations included transthoracic echocardiogram for exclusion of structural cardiac disease and laboratory tests for exclusion of metabolic and electrolyte abnormalities&#46; Intravenous flecainide&#44; a sodium-channel-blocking agent&#44; was used for provocative pharmacological tests &#40;2 mg&#47;kg bodyweight over 10 min with a maximum dose of 150 mg&#41;&#46; EPS was performed with two drive cycles &#40;600 and 400 ms&#44; S1&#41; and a maximum of three ventricular extrastimuli &#40;S2&#44; S3 and S4&#41; delivered from two different ventricular sites &#40;right ventricular apex and right ventricular outflow tract&#41;&#44; unless VF or sustained VT &#40;lasting &#62;30 s&#41;&#44; causing syncope&#44; or requiring intervention for termination&#44; was elicited in a previous step&#46; Minimum coupling interval was 200 ms for S2 to S4&#46; A positive EPS was defined as induced VF&#44; sustained polymorphic VT or polymorphic syncopal VT requiring direct current shock&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Implantable cardioverter-defibrillator implantation and follow-up</span><p id="par0035" class="elsevierStylePara elsevierViewall">ICDs were implanted according to the criteria recommended in the second consensus report on Brugada syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">6</span></a> Implantation was performed with a transvenous system in all patients&#44; through the cephalic or left subclavian vein at the operator&#39;s discretion&#46; It is our routine protocol to program a single VF zone with a detection rate of 180&#8211;200 bpm and backup pacing at a rate of 45 bpm for these patients&#46; Appropriate shocks were defined as shocks delivered for VT or VF&#59; inappropriate shocks were defined as shocks delivered in the absence of ventricular arrhythmia&#46; The main endpoint assessed during a mean follow-up of 74&#177;40 months &#40;&#62;5 years in 72&#37; of cases&#41; was the occurrence of appropriate shocks&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Continuous variables were expressed as mean &#177; standard deviation&#46; Discrete variables were expressed as frequencies and percentages&#46; Statistical comparisons of baseline characteristics and outcomes were performed using the chi-square test or Fisher&#39;s exact test&#44; as appropriate&#44; for categorical variables and the Student&#39;s t test for continuous variables&#46; Corrected risk estimates were performed using a Cox proportional hazard regression model including the following variables&#58; spontaneous type 1 ECG pattern&#44; history of syncope&#44; aborted SCD and NSVT during follow-up&#46; For this analysis the time to first appropriate shock was considered&#46; Receiver operating characteristic &#40;ROC&#41; analysis was performed with determination of the area under the curve &#40;AUC&#41; and respective specificity&#44; sensitivity&#44; positive and negative predictive values&#46; Two-tailed tests of significance are reported&#46; For all comparisons&#44; a p value of &#60;0&#46;05 was considered statistically significant&#46; When appropriate&#44; 95&#37; confidence intervals &#40;CI&#41; were calculated&#46; The statistical analysis was performed with SPSS version 19&#46;0 &#40;SPSS Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Patient characteristics</span><p id="par0045" class="elsevierStylePara elsevierViewall">Of the 55 patients with Brugada syndrome included in the present analysis&#44; 36 &#40;65&#46;5&#37;&#59; mean age 41&#46;7&#177;13&#46;8 years&#59; 81&#46;8&#37; male&#41; underwent ICD implantation&#46; The baseline characteristics of these patients are depicted in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Briefly&#44; 19 &#40;52&#46;8&#37;&#41; patients were asymptomatic&#44; 11 &#40;30&#46;6&#37;&#41; had a previous history of syncope &#40;with a possible arrhythmic cause suspected in eight patients&#41;&#44; six &#40;16&#46;7&#37;&#41; had aborted SCD and 14 &#40;38&#46;9&#37;&#41; had a family history of SCD&#46; Spontaneous type 1 ECG pattern was present in 25 &#40;69&#46;4&#37;&#41; patients&#46; EPS was performed in 26 &#40;72&#46;2&#37;&#41; patients&#44; with positive results in 22 &#40;84&#46;6&#37;&#41;&#46; Provocative testing with flecainide was performed in 14 &#40;38&#46;9&#37;&#41; patients&#46; Indications for ICD implantation are represented in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Outcome and follow-up analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">During a mean follow-up of 74&#177;40 months &#40;&#62;5 years in 72&#37; of cases&#41;&#44; seven patients experienced appropriate shocks&#44; corresponding to an incidence of 19&#46;4&#37; and an annual event rate of 2&#46;8&#37;&#46; Four patients had arrhythmic storm &#40;successfully treated with quinidine&#41;&#46; Median time to the first appropriate shock was 17 months&#44; all events occurring between 3 and 51 months after ICD implantation&#46; With regard to clinical presentation&#44; the rate of appropriate shocks was significantly lower in asymptomatic patients than in those with a history of syncope and aborted SCD&#58; 10&#46;5&#37;&#44; 18&#46;2&#37; and 66&#46;7&#37;&#44; respectively &#40;p&#61;0&#46;007&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The majority of patients with appropriate shocks were men&#44; with aborted SCD and spontaneous type 1 ECG pattern &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; Comparing patients with and without appropriate shocks&#44; the first group had a statistically significant higher prevalence of aborted SCD &#40;54&#46;1&#37; vs&#46; 6&#46;9&#37;&#44; p&#61;0&#46;008&#41; and NSVT &#40;57&#46;1&#37; vs&#46; 10&#46;3&#37;&#44; p&#61;0&#46;016&#41; during follow-up&#46; Spontaneous type 1 ECG pattern&#44; family history of SCD&#44; syncope and positive EPS did not present a statistically significant association with appropriate shocks &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In the two patients with syncope at presentation and appropriate shocks during follow-up&#44; an arrhythmic cause for syncope was suspected&#46; Multivariate analysis adjusted for statistically significant characteristics in univariate analysis &#40;aborted SCD and NSVT during follow-up&#41; and for spontaneous type 1 ECG pattern and history of syncope revealed independent predictors of appropriate shocks to be aborted SCD &#40;hazard ratio &#91;HR&#93; 7&#46;87&#44; 95&#37; CI 1&#46;27&#8211;49&#46;6&#59; p&#61;0&#46;027&#41; and NSVT during follow-up &#40;HR 6&#46;73&#44; 95&#37; CI 1&#46;27&#8211;35&#46;7&#59; p&#61;0&#46;025&#41;&#46; By ROC curve analysis&#44; aborted SCD had moderate discriminatory power to predict the occurrence of appropriate shocks &#40;AUC&#61;0&#46;751&#41;&#44; with sensitivity and specificity of 57&#37; and 93&#37;&#44; respectively &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; None of the patients died during follow-up&#46; In terms of ICD-related complications&#44; eight &#40;22&#46;2&#37;&#41; patients had inappropriate shocks during the follow-up period&#44; mainly due to sinus tachycardia &#40;five patients&#41;&#44; mainly managed by increasing ICD thresholds or by beta-blocker therapy&#46; One patient had documented lead infection and underwent device replacement and another had a lead fracture&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">During the mean follow-up of 69&#177;31 months&#44; the 19 patients without ICD implantation were alive&#44; and only one underwent ICD implantation&#44; without occurrence of appropriate shocks&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Brugada syndrome is an arrhythmogenic disease associated with a high risk of SCD in young individuals with structurally normal hearts&#44; and is classically characterized by an ECG phenotype of right bundle branch block and ST-segment elevation in the right precordial leads&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#44;9</span></a> The prevalence of the syndrome is difficult to estimate since ECG findings can be dynamic and&#47;or concealed&#44; and there are potentially endemic regions for the genetic alterations associated with this entity &#40;mutations in the <span class="elsevierStyleItalic">SCN5A</span> sodium channel gene&#41;&#46; Its prevalence is estimated at approximately 5&#47;10 000 individuals&#44; with a higher prevalence in Asia&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">10&#8211;13</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Risk stratification of SCD is essential to the management of patients with Brugada syndrome&#46; The objective is to identify patients at higher risk of SCD who may benefit from ICD implantation&#44; the only measure with proven survival benefit in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> A substantial part of the evidence for the advantages of an ICD comes from the results of the DEBUT trial&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">14</span></a> No pharmacological therapy has shown to improve survival in Brugada syndrome patients&#44; but class IA antiarrhythmic drugs&#44; particularly quinidine&#44; which inhibit the potassium transient outward current of the action potential&#44; may be useful in refractory cases&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In the present study&#44; performed in patients with Brugada syndrome who received an ICD for primary or secondary prevention&#44; the long-term &#40;mean follow-up of 6&#46;2 years&#41; annual event rate of potentially life-threatening ventricular arrhythmias was 2&#46;8&#37;&#47;year&#46; The rate of appropriate ICD shocks was similar to results previously published by Rosso et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> and Sacher et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> despite the longer follow-up in our analysis&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Several characteristics have been described as predictors of the occurrence of arrhythmic events in Brugada syndrome patients&#46; Aborted SCD&#44; history of syncope&#44; spontaneous type 1 ECG pattern and positive EPS are associated with increased risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">2&#44;18</span></a> However&#44; distribution of these characteristics among different published studies is not homogeneous&#46; In the FINGER registry&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> during a mean follow-up of 32 months&#44; cardiac events &#40;appropriate shocks or SCD&#41; were recorded in 5&#37; of Brugada patients&#46; Independent predictors of the event were aborted SCD&#44; syncope and spontaneous type 1 ECG&#46; In fact&#44; a history of syncope and aborted SCD are the most common clinical manifestations in Brugada syndrome patients&#44; predominantly manifested in men during the third and fourth decades of life&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">15</span></a> Nevertheless&#44; a significant number of patients with Brugada syndrome are asymptomatic at the time of diagnosis&#46; These patients have a more favorable long-term prognosis compared with those with symptomatic presentation &#40;e&#46;g&#46; aborted SCD&#44; syncope or symptomatic VT&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">When analyzed in a multivariate model&#44; aborted SCD and NSVT during follow-up were the only independent predictors of appropriate shocks in our analysis&#46; Aborted SCD had moderate discriminatory power to predict this outcome&#46; It is important to recall that an appropriate shock is not synonymous with SCD&#46; Although a proven relation between aborted SCD and the risk of arrhythmic events in Brugada syndrome patients has been frequently reported&#44; an independent association of NSVT with appropriate shocks during follow-up has also been described&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a> However&#44; it should be borne in mind that NSVT episodes saved in the ICD data log are dependent on the heart rate and duration in the device programming&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The association between syncope and the occurrence of appropriate shocks remains somewhat controversial&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">22&#44;23</span></a> In our study&#44; syncope was the major symptom at diagnosis&#44; mainly of arrhythmic origin&#44; but was not significantly associated with the occurrence of appropriate shocks at long-term follow-up&#46; Similarly to our results&#44; in a study by Sarkozy et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a> syncope was not a predictor of arrhythmic events after prophylactic ICD implantation&#46; Unfortunately&#44; sometimes it is not easy to differentiate the origin of syncope between benign &#40;reflex&#41; or potentially fatal &#40;VT&#41;&#46; This difficulty suggests that patients with benign syncope may have comprised a significant part of our syncopal population&#44; which may have distorted the results&#46; In another analysis of 203 patients with Brugada syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> the prevalence of syncope was 28&#37; and in many cases a cardiac etiology was considered unlikely&#46; The follow-up of these patients showed that long-term arrhythmic events occurred only in patients with syncope of cardiac origin&#46; Similarly&#44; in our study events occurred only in patients with possible arrhythmic syncope&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Type 1 ECG pattern and inducibility during EPS were not predictors of appropriate shocks&#46; The role of EPS in risk stratification and management of Brugada syndrome patients is not well established&#44; with published data revealing conflicting results&#46; Brugada et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> suggest that VT&#47;VF induction in asymptomatic patients is significantly correlated with an increased risk of SCD&#59; on the other hand&#44; Priori et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> suggest that EPS does not add significant value to risk stratification in either symptomatic or asymptomatic patients&#46; These discrepancies may be explained by the differences in baseline characteristics of the study populations and the different stimulation protocols&#46; In fact&#44; it is known that programmed stimulation induces VF in 6&#8211;9&#37; of apparently healthy individuals&#44; representing false positives&#44; particularly when more aggressive protocols are used&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">26&#44;27</span></a> Paul et al&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> performed a meta-analysis to assess the role of programmed ventricular stimulation in patients with Brugada syndrome&#44; and showed that EPS did not have a significant role in predicting arrhythmic events during follow-up&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In our study a family history of SCD in first-degree relatives was not associated with an increased risk of arrhythmic events during follow-up&#46; This finding is in agreement with the results of several previously published studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">17&#44;19&#44;24</span></a> A positive provocative pharmacological test with flecainide also failed to identify patients with increased risk of appropriate shocks&#44; as described in the PRELUDE Registry&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Our results support both the importance of ICD implantation in SCD survivors and the current non-invasive strategy of close follow-up&#44; without device implantation&#44; in asymptomatic patients&#46; In patients with syncope&#44; discrepancies from previous results highlight the need for better discrimination of the nature of syncope &#40;arrhythmic vs&#46; reflex&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Only two patients had severe complications associated with ICD implantation &#40;infection and lead fracture&#41; requiring device replacement&#44; while eight patients had inappropriate shocks during follow-up&#46; Given the young age and active lifestyle of our patients&#44; many engaging in regular sports&#44; it is not surprising that the leading cause of inappropriate shocks was sinus tachycardia&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">17&#44;19</span></a> The rate of ICD complications exceeding the rate of arrhythmic events during follow-up has been previously reported&#44;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">21&#44;29</span></a> highlighting the importance of an accurate risk stratification scheme&#46; Inappropriate patient selection for ICD implantation may result in a considerable increase in healthcare costs and may expose asymptomatic individuals to ICD-related complications&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The present study has some limitations&#46; It is retrospective and the small number of patients and the low event rate during follow-up make it difficult to draw any definitive conclusions regarding predictors of long-term outcome&#46; Some ventricular tachyarrhythmias may terminate spontaneously&#44; depending on how the device is programmed&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">Long-term prognostic analysis of patients with Brugada syndrome and an ICD implanted for primary or secondary prevention revealed an annual event rate of potentially life-threatening ventricular arrhythmias of 2&#46;8&#37;&#47;year&#46; Aborted SCD and NSVT during follow-up were independent predictors of the occurrence of appropriate shocks&#44; whereas syncope&#44; type 1 ECG pattern&#44; EPS and family history of SCD were not associated with a higher rate of events in this population&#46; The number of patients with inappropriate shocks was similar to the number of patients with appropriate shocks&#44; and two patients had serious ICD-related complications&#46; Risk stratification of patients with Brugada syndrome remains controversial and the risk&#47;benefit ratio of this therapy should be taken into account&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Ethical disclosures</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Protection of human and animal subjects</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Risk stratification of Brugada syndrome &#40;BrS&#41; remains controversial and recommendations for an implantable cardioverter-defibrillator &#40;ICD&#41; are not well established&#46; The objective of this study was to assess the long-term prognosis of BrS patients with an ICD&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods and Results</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Of 55 consecutive patients with BrS assessed between April 2002 and October 2012&#44; 36 &#40;mean age 41&#46;7&#177;13&#46;8 years&#59; 81&#46;8&#37; male&#41; underwent ICD implantation&#46; Nineteen &#40;52&#46;8&#37;&#41; were asymptomatic&#44; 11 &#40;30&#46;6&#37;&#41; had previous history of syncope &#40;arrhythmic cause suspected in eight&#41; and six &#40;16&#46;7&#37;&#41; had aborted sudden cardiac death &#40;SCD&#41;&#46; Spontaneous type 1 electrocardiographic &#40;ECG&#41; pattern was present in 25 &#40;69&#46;4&#37;&#41; patients and electrophysiological study &#40;EPS&#41;&#44; performed in 26 &#40;72&#46;2&#37;&#41;&#44; was positive in 22 &#40;84&#46;6&#37;&#41;&#46; During a mean follow-up of 74&#177;40 months &#40;&#62;5 years in 72&#37; of cases&#41;&#44; seven &#40;19&#46;4&#37;&#41; patients had appropriate shocks &#40;annual event rate 2&#46;8&#37;&#41;&#46; These patients most frequently had aborted SCD &#40;54&#46;1&#37; vs&#46; 6&#46;9&#37;&#59; p&#61;0&#46;008&#41; and nonsustained ventricular tachycardia &#40;57&#46;1&#37; vs&#46; 10&#46;3&#37;&#59; p&#61;0&#46;016&#41; during follow-up&#46; Spontaneous type 1 ECG pattern&#44; syncope and positive EPS were not significantly associated with appropriate shocks&#46; Multivariate analysis revealed that aborted SCD was an independent predictor of appropriate shocks &#40;HR 8&#46;07&#44; 95&#37; CI 1&#46;58&#8211;41&#46;2&#59; p&#61;0&#46;012&#41;&#46; ROC curve analysis demonstrated that aborted SCD had moderate discriminatory power to predict appropriate shocks &#40;AUC 0&#46;751&#41;&#44; with sensitivity of 57&#37; and specificity of 93&#37;&#46; In terms of ICD-related complications&#44; eight &#40;22&#46;2&#37;&#41; patients had inappropriate shocks during the follow-up period&#44; mainly due to sinus tachycardia &#40;five patients&#41;&#59; one patient had lead infection and another had a lead fracture&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In this population of BrS patients with ICD&#44; the long-term rate of appropriate shocks was 2&#46;8&#37;&#47;year&#46; Aborted SCD was associated with a higher risk of appropriate shocks&#44; whereas syncope and spontaneous type I ECG pattern did not predict this event&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods and Results"
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            "identificador" => "abst0015"
            "titulo" => "Conclusion"
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        "titulo" => "Resumo"
        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introdu&#231;&#227;o</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A estratifica&#231;&#227;o de risco na s&#237;ndrome de Brugada &#40;SB&#41; permanece controversa e as recomenda&#231;&#245;es para cardiodesfibrilhador &#40;CDI&#41; n&#227;o est&#227;o bem definidas&#46; O objetivo deste estudo foi avaliar o progn&#243;stico a longo prazo de doentes com SB e CDI implantado&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">M&#233;todos e resultados</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">De 55 doentes consecutivos com SB avaliados entre abril&#47;2002-outubro&#47;2012&#44; 36 &#40;idade m&#233;dia 41&#44;7&#177;13&#44;8 anos&#59; 81&#44;8&#37; homens&#41; implantaram CDI&#46; Dezanove &#40;52&#44;8&#37;&#41; eram assintom&#225;ticos&#44; 11 &#40;30&#44;6&#37;&#41; tinham hist&#243;ria de s&#237;ncope &#40;oito com suspeita de causa arr&#237;tmica&#41; e seis &#40;16&#44;7&#37;&#41; foram reanimados de morte s&#250;bita &#40;MS&#41;&#46; O eletrocardiograma &#40;ECG&#41; com padr&#227;o tipo 1 espont&#226;neo estava presente em 25 &#40;69&#44;4&#37;&#41; doentes e foi realizado estudo eletrofisiol&#243;gico &#40;EEF&#41; em 26 &#40;72&#44;2&#37;&#41;&#44; sendo positivo em 22 &#40;84&#44;6&#37;&#41;&#46; Durante o per&#237;odo de seguimento m&#233;dio de 74&#177;40 meses &#40;&#62;5 anos em 72&#37; dos casos&#41;&#44; sete &#40;19&#44;4&#37;&#41; doentes tiveram choques apropriados &#40;incid&#234;ncia anual 2&#44;8&#37;&#41;&#46; Estes doentes tinham mais frequentemente hist&#243;ria de MS abortada &#40;54&#44;1 <span class="elsevierStyleItalic">versus</span> 6&#44;9&#37;&#59; p&#61;0&#44;008&#41; e taquicardia n&#227;o mantida &#40;57&#44;1 <span class="elsevierStyleItalic">versus</span> 10&#44;3&#37;&#59; p&#61;0&#44;016&#41; durante o seguimento&#46; Padr&#227;o ECG tipo 1 espont&#226;neo&#44; s&#237;ncope e EEF positivo n&#227;o se associaram significativamente &#224; ocorr&#234;ncia de choques apropriados&#46; Em an&#225;lise multivariada a MS abortada manteve-se preditor independente de choques apropriados &#40;HR 8&#44;07 IC95&#37; 1&#44;58-41&#44;2&#59; p&#61;0&#44;012&#41;&#46; Em an&#225;lise de curvas ROC a MS abortada apresentou um poder discriminat&#243;rio moderado para predizer choques apropriados &#40;AUC 0&#44;751&#41; &#8211; sensibilidade 57&#37; e especificidade 93&#37;&#46; Relativamente &#224;s complica&#231;&#245;es relacionadas com o CDI&#44; oito &#40;22&#44;2&#37;&#41; doentes tiveram choques inapropriados durante o per&#237;odo de seguimento&#44; sobretudo por taquicardia sinusal &#40;cinco doentes&#41;&#44; um infe&#231;&#227;o de el&#233;trodo e outro fratura de el&#233;trodo&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclus&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Na popula&#231;&#227;o estudada de doentes com SB e CDI implantado a incid&#234;ncia de choques apropriados foi 2&#44;8&#37;&#47;ano&#46; A MS abortada associou-se a um maior risco de choques apropriados&#44; enquanto a s&#237;ncope e o padr&#227;o de ECG tipo 1 espont&#226;neo n&#227;o foram preditores deste evento&#46;</p></span>"
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            "titulo" => "Introdu&#231;&#227;o"
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            "titulo" => "M&#233;todos e resultados"
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            "identificador" => "abst0030"
            "titulo" => "Conclus&#227;o"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Indications for ICD implantation in the study population&#46; ECG&#58; electrocardiogram&#59; EPS&#58; electrophysiological study&#59; ICD&#58; implantable cardioverter-defibrillator&#59; SCD&#58; sudden cardiac death&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Survival analysis comparing clinical presentation&#58; aborted SCD vs&#46; syncope vs&#46; asymptomatic patients &#40;p&#61;0&#46;007&#41;&#46; SCD&#58; sudden cardiac death&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">ECG&#58; electrocardiogram&#59; EPS&#58; electrophysiological study&#59; SCD&#58; sudden cardiac death&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Demographic</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;7&#177;12&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;83&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Caucasian&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35 &#40;97&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Clinical</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aborted SCD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;16&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Syncope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;30&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;52&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Family history of SCD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;38&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Electrocardiographic</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Type 1 ECG pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;69&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Type 2 ECG pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;22&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Without typical ECG pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Diagnostic workup and therapeutic approach</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>EPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;72&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Positive EPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;84&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Provocative test with flecainide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;38&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of patients with ICD &#40;n&#61;36&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">ECG&#58; electrocardiogram&#59; EPS&#58; electrophysiological study&#59; NSVT&#58; non-sustained ventricular tachycardia&#59; SCD&#58; sudden cardiac death&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Shocks &#40;n&#61;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No shocks &#40;n&#61;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;85&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;82&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Aborted SCD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;57&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;6&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Syncope&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;31&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Family history of SCD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;28&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;41&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;681&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Spontaneous type 1 ECG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;71&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;69&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Positive EPS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;42&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;65&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;394&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">NSVT &#40;follow-up&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;57&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;10&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Comparison of patients according to the occurrence of appropriate shocks&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">AUC&#58; area under the curve&#59; ECG&#58; electrocardiogram&#59; EPS&#58; electrophysiological study&#59; PPV&#58; positive predictive value&#59; NPV&#58; negative predictive value&#59; NSVT&#58; non-sustained ventricular tachycardia&#59; SCD&#58; sudden cardiac death&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;272&#8211;0&#46;752&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;920&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Positive EPS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;149&#8211;0&#46;625&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;358&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;058&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Predictive value for appropriate shocks of different characteristics&#46;</p>"
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    ]
    "bibliografia" => array:2 [
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                            1 => "C&#46; Napolitano"
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                          "colaboracion" => "American College of Cardiology&#47;American Heart Association Task Force&#59; European Society of Cardiology Committee for Practice Guidelines&#59; European Heart Rhythm Association&#59; Heart Rhythm Society"
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2015.06.001

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Year/Month	Html	Pdf	Total

2024 November	9	5	14
2024 October	52	30	82
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2024 August	39	27	66
2024 July	27	31	58
2024 June	37	21	58
2024 May	29	26	55
2024 April	40	24	64
2024 March	41	18	59
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2023 December	36	25	61
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2023 August	24	18	42
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2023 May	45	38	83
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2023 March	60	20	80
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2022 October	41	16	57
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2022 July	63	31	94
2022 June	48	25	73
2022 May	36	32	68
2022 April	39	23	62
2022 March	57	31	88
2022 February	55	23	78
2022 January	36	18	54
2021 December	16	30	46
2021 November	29	33	62
2021 October	29	29	58
2021 September	31	36	67
2021 August	32	24	56
2021 July	31	34	65
2021 June	26	18	44
2021 May	49	30	79
2021 April	67	39	106
2021 March	60	21	81
2021 February	59	15	74
2021 January	53	15	68
2020 December	49	8	57
2020 November	38	11	49
2020 October	30	5	35
2020 September	66	8	74
2020 August	34	2	36
2020 July	51	11	62
2020 June	44	15	59
2020 May	70	9	79
2020 April	56	8	64
2020 March	50	14	64
2020 February	101	20	121
2020 January	40	8	48
2019 December	28	10	38
2019 November	31	11	42
2019 October	37	8	45
2019 September	54	19	73
2019 August	31	10	41
2019 July	25	9	34
2019 June	25	43	68
2019 May	36	9	45
2019 April	12	13	25
2019 March	38	12	50
2019 February	43	12	55
2019 January	32	14	46
2018 December	52	13	65
2018 November	142	20	162
2018 October	436	22	458
2018 September	97	11	108
2018 August	22	5	27
2018 July	27	2	29
2018 June	58	6	64
2018 May	69	8	77
2018 April	156	6	162
2018 March	88	13	101
2018 February	116	6	122
2018 January	165	4	169
2017 December	261	8	269
2017 November	73	8	81
2017 October	38	8	46
2017 September	36	8	44
2017 August	37	18	55
2017 July	33	14	47
2017 June	50	15	65
2017 May	51	23	74
2017 April	33	6	39
2017 March	42	6	48
2017 February	23	10	33
2017 January	22	12	34
2016 December	20	9	29
2016 November	17	5	22
2016 October	36	5	41
2016 September	25	10	35
2016 August	9	4	13
2016 July	9	12	21
2016 June	7	7	14
2016 May	14	14	28
2016 April	22	1	23
2016 March	17	17	34
2016 February	21	17	38
2016 January	29	15	44
2015 December	37	15	52
2015 November	30	12	42
2015 October	34	6	40
2015 September	34	16	50
2015 August	49	19	68
2015 July	66	27	93
2015 June	21	1	22

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