Lee et al, Am J Cardiol 2014

Firenze, 8 Novembre 2014
Extrasistolia
nel
Cuore Sano
Dr. P. Pieragnoli
Università degli Studi di Firenze
D’Este et al, G Ital Cardiol 2010
Extrasistolia ventricolare che
origina dal fascicolo posteriore
della branca sinistra.
Morfologia del QRS a tipo
blocco di branca destra ed
emiblocco anteriore sinistro.
Extrasistolia ventricolare dal
tratto di efflusso del ventricolo
destro.
Morfologia del QRS a tipo
blocco di branca sinistra con
asse verticale.
D’Este et al, G Ital Cardiol 2010
Characteristic appearance of ectopy from the right ventricular outflow tract
Giles et al, Canadian Journal of Cardiology 2013
Displasia aritmogena del
ventricolo destro.
Morfologia del QRS a tipo
blocco di branca sinistra.
Sindrome del QT lungo congenito.
Allungamento dell’intervallo QT
soprattutto nei battiti postextrasistolici.
D’Este et al, G Ital Cardiol 2010
Extrasistolia ventricolare in un caso di fibrillazione ventricolare idiopatica.
Le extrasistoli sono precoci ed hanno morfologia bizzarra.
D’Este et al, G Ital Cardiol 2010
Kennedy et al. NEJM 1985
Ataklte et al, Am J Cardiol 2013
Association of VPCs with risk for
Sudden Cardiac Death
Ataklte et al, Am J Cardiol 2013
Association of VPCs with risk for
Total Cardiac Death
Ataklte et al, Am J Cardiol 2013
Presence of PVCs is associated with a pooled OR of 1.72 (95% CI 1.28 to 2.31) of
developing all-cause mortality, cardiovascular mortality, SCD or ischaemic heart
disease when compared with patients without any PVCs.
Lee V et al, Heart 2012
Our paper has shown that the current evidence base on
the exact prognosis of PVCs in structurally normal
hearts is limited and has many flaws. Most studies on
the prognosis of PVCs in normal hearts did not use
advanced tests to rule out structural heart disease.
Among these patients, PVCs are associated with a
worse cardiovascular outcome, and this risk is
correlated to the age and underlying cardiovascular
risk of the patient population, suggesting that the poor
prognosis studies may have inadvertently included
patients with occult structural heart disease, the
population in which PVCs are known to confer adverse
outcomes. More studies are required.
Lee V et al, Heart 2012
Giles et al, Canadian Journal of Cardiology 2013
Biffi et al. JACC 2002
Biffi et al. JACC 2002
Frequent
and
complex
ventricular
tachyarrhythmias are common in trained
athletes and are usually unassociated with
underlying
cardiovascular abnormalities.
Such
ventricular
arrhythmias
(when
unassociated
with
cardiovascular
abnormalities) do not convey adverse clinical
significance, appear to be an expression of
“athlete’s heart syndrome,” and probably do
not per se justify a disqualification from
competitive sports.
Biffi et al. JACC 2002
Median number of VPCs in
the basal condition and
during follow-up in subjects
who had a normal (>55%) or
abnormal (55%) EF at the
end of follow up.
Behavior of the median number of
VPCs/24 hours during followup
in subjects who continued sporting
activity and in those who did not.
The number of VPCs/24 hours
decreased significantly in both
groups.
Delise et al, Am J Cardiol 2013
Basal VPCs
VPCs during Follow-up
The best cutoffs to predict low left ventricular EF at the end of follow-up, based on
receiver operating characteristic curve analysis of the number of basal and final
VPCs, were 5873 and 10436 VPCs/24 hours, respectively.
Delise et al, Am J Cardiol 2013
Premature ventricular contraction
(PVC) burden and its effect on
LV function.
The relation of VPC burden to (A)
LVEF and (B) left ventricular endsystolic dimension (LVESD).
Lee et al, Am J Cardiol 2014
Kaplan-Meier survival estimates of PVC burdens.
Significant difference among patient groups with PVC burden <1,000/24h, 1,000 to
10,000/24h, and >10,000/24h
Lee et al, Am J Cardiol 2014
Kaplan-Meier
survival
estimates of PVC features.
Survival rates were lower in
patients with a PVC QRS
duration of 150ms than
those with a PVC QRS
duration of <150ms (A)
Survival rates were lower in
patients with a PVC coupling
interval of >480 ms than
those with a PVC coupling
interval of 480 ms (B).
Lee et al, Am J Cardiol 2014
Kaplan-Meier
survival
estimates
of
PVC
origins.
The
comparison
of
survival rates between the
VPCs originating from (A)
OT and non-OT locations
and (B) between the RV
and the LV.
Lee et al, Am J Cardiol 2014
Ephrem et al
Ann Noninvasive Electrocardiol 2013
Time to adverse event by
frequency
Time to adverse event by
pattern
Ephrem et al
Ann Noninvasive Electrocardiol 2013
Qureshi W et al, Am J Cardiol 2013
VPC
APC
All-Cause Mortality
VPC
Ischemic Heart
Disease Mortality
APC
VPC
Cardiovascular
Disease Mortality
APC
Qureshi W et al, Am J Cardiol 2013
These
findings
highlight
the
potential use of electrocardiography
as a screening tool in asymptomatic
patients
to
detect
subclinical
cardiac disease.
Further studies are needed to
validate our findings and evaluate
the mechanisms by which APCs are
associated with poor outcomes.
Qureshi W et al, Am J Cardiol 2013
Heidbuchel et al, European Heart J 2003
Role of SEF
Heidbuchel et al, European Heart J 2003
Alterations in intracellulare
calcium and membrane ionic
currents
Tachicardia
Induced
Cardiomyopathy
Ventricular
Dyssynchrony
Hemodynamic impairment
PVC-INDUCED
CARDIOMYOPATHY
Increased Oxygen
consumption
Alterations in
heart rate
dynamics
Myocardial and pheripheral
vascular autonomic
dysregulation
Yong-Mei Cha et al, Circulation 2012
Yong-Mei Cha et al, Circulation 2012
Krittayaphong et al, Am J Cardiol 2014
Comparison of percent improvement of symptoms, PVC count, and average heart rate as
measured by AECG, and QOL score be- tween the atenolol group and the placebo group
(positive direction represents reduction in symptoms, PVC count, and heart rate, and an
increase in QOL score)
Krittayaphong et al, Am J Cardiol 2014
Minhua Zang et al, Heart Bmj 2014
Minhua Zang et al, Heart BMJ 2014
Effect of Ablation
Change in LVEF post-Ablation
Change in LVEDd post-Ablation
Minhua Zang et al, Heart Bmj 2014
Benigne PVC from RV Outflow Tract
Surface EKG
Endocardial Ablation
Miyamoto et al., Circ J 2010
Benigne PVC from Outflow Tract
Surface EKG
Epicardic Ablation
Tanner et al., JACC 2005
Yokakawa et al., Heart Rhythm 2013
Conclusions: Frequent PVCs can induce subtle cardiac dysfunction detected by
speckle tracking imaging analysis in patients without apparent cardiomyopathy. RFCA
can successfully eliminate PVCs and improve cardiac function.
Wijnmaalen et al., Heart 2010
Baser et al., J Cardiovasc Electrophysiol 2014
Preablation and 3 months postablation PVC
burden in patients with an acutely effective
versus an acutely failed procedure. There was
no significant difference in the PVC burden
preablation. The PVC burden at 3 months
postablation was significantly reduced.
Site of origin of predominant
PVCs. The numbers in
parentheses indicate number of
patients with success/failure at 3
months postablation.
Baser et al., J Cardiovasc Electrophysiol 2014
Conclusioni 1
In assenza di una dimostrata cardiopatia di base i BPV
frequenti non sembrano avere in sè una potenziale
evolutività verso aritmie maligne e comportare quindi un più
elevato rischio di morte improvvisa.
Un numero molto elevato di BPV nelle 24 ore (>2000)
si accompagna più facilmente a polimorfismi e forme
complesse, aspetti quest’ultimi caratterizzati da maggior
prevalenza di cardiopatia.
È necessario che il cardiologo escluda con ragionevole
sicurezza la presenza di una cardiopatia prima di
assolvere i BPV dal sospetto di essere markers e spie di
patologie latenti, subcliniche o molecolari.
Conclusioni 2
Sotto il profilo terapeutico, solo la presenza di una
cardiopatia giustifica provvedimenti farmacologici con
antiaritmici, prescritti in modo personalizzato.
In casi altamente selezionati anche in questo campo risulta
vantaggioso il ricorso alle tecniche di ablazione con
radiofrequenza.
Per quanto riguarda gli atleti bisogna ricordare l’efficacia del
detraining sul controllo dei BPV e l’importanza dell’indagine
relativa all’assunzione di sostanze illecite, la cui sospensione
è spesso sufficiente a risolvere il problema aritmico nei casi
senza patologia cardiaca.