Brugada Patient and the Environment: Harmful Factors and Drugs Juhani Junttila, MD Insitute of Clinical Medicine, University of Oulu, Oulu, Finland

Case 50 yrs male Paroxysmal Afib Treated with flecainide No family history of SCD No syncopal episodes

Case Flecainide discontinued RBBB underlying morphology??

Induced Brugada ECG Patients with induced Brugada ECG by medication of by fever are at imminent risk for ventricular arrhythmias In a case series of 47 patients with induced Brugada ECG 51% developed ventricular arrhythmias Most cases had ventricular arrhythmias during fever or during anesthesia Junttila MJ et al. Circulation 2008

Ion channel effects Ito Ito ICa INa IKr INa IKs

Fever Current decay for WT (squares) and Thr1620Met (circles) at 22°C (▪, •) and 32°C (□, ○). Dumaine R et al. Circulation Research 1999;85:803-809

Fever 402 patients with fever (>38°) and 909 without 2% (n= 8) type I Brugada ECG in fever patients 0.1% in controls, p< 0.001 Four had diagnostic finging of the syndrome after fever One Brugada ECG in repeated ECG Three with positive ajmaline test All patients with Brugada ECG were asymptomatic and remained asymptomatic during 30mo of follow up Adler A et al. Heart Rhythm. 2013

Fever

Sauna and Hot Tub Sauna: 30min in 80C° core temperature increase ~1C° in adults and ~2C° in children Leppäluoto J. Ann Clin Res. 1988;20(4):240-3 Hot tub: 15min of 40C° increased core body temperature by ~0.6C° Allison TG, Miller TD, Squires RW et al. Mayo Clin Proc. 1993 Jan;68(1):19-25.

Sports Strenuous indurance training might be harmful Increase in vagal tone? Leisure-time sport activity might not be harmful Patients with ICD should be restricted from competetive sports? Sports with low cardiovascular demand should be allowed Heidbüchel H et al. Study Group on Sports Cardiology of the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2006

Other factors Hypokalemia Glucose-insulin infusion Araki T et al. Circ J. 2003 Glucose-insulin infusion Nogami A et al. Pacing Clin Electrophysiol. 2003

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

Drugs –preferably avoided www.brugadadrugs.org Postema et al. Heart Rhythm 2009 and Postema et al. Europace 2013

Drugs Propofol infusion syndrome Well known among anesthesiologists Brugada ECG among first warning signs Lactic acidosis results in organ failure

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