Effect Of Surface Ecg Lead Positioning On The ECG Appearance Of J Wave Syndromes

1
Effect Of Surface Ecg Lead Positioning On The ECG
Appearance Of J Wave Syndromes

• Noon Conference, October
• Shrin Hebsur MD

2
J Wave Syndrome

• Two major types

Early Repolarization Syndrome
Brugada Syndrome
3
Early Repolarization Syndrome

• Occurs in 1-2 of population
• More common in young males
• Cocaine abusers
• HOCM patients
• ECG Characteristics include
• Notch in downsloping R wave (J wave)
• Concave STE with upright T wave
• Predominantly seen in V2-V5
• Clinical Significance
• Is it benign?

4
Brugada Syndrome

• ST elevation in asymptomatic individuals causing
  sudden cardiac death
• Prevalence 5-66/100,000
• Increased amongst SE Asians, atheletes
• Genetics numerous genes identified, Autosomal
  dominant with incomplete penetrance
• Classic ECG characteristic RSR, Inverted T in
  V1-3 (Right Ventricular Leads)

5
Cardiac Action Potential
6
Creating J wave
7
Early Repolarization ECG
8
Brugada AP
9
Brugada ECG
10
Similarities between ERS and Brugada
11
Surface ECG leads can tell different story
Young male prior to V.Fib arrest
12
ECG leads to look at Right Ventricle
13
Surface ECG leads in -2 position
14
Purpose

• Brugada and Early Repolarization are very similar
  in presentation with distinct outcome differences
• In patients with higher clinical suspicion, would
  a modified ECG help in diagnosis and triage?

15
Hypothesis
By manipulating ECG electrodes to better capture
transmural thickness of right ventricle, early
repolarization and or Brugada Syndrome can be
elicited.
16
Selecting Patients

• Patients
• Recruited patients coming into EP lab for EP
  studies, ICD placements, Tilt Table tests. Goal
  N500
• Exclusion Criteria
• Pregnancy
• Acute Coronary Syndrome
• Aborted Cardiac Arrest
• Brugada Syndrome
• Acute Pericarditis
• Any drug overdose
• Use of Left Ventricular Assist Device
• Any terminal illness
• BMI gt 35
• Paced Rhythm

17
Methods

• 12 lead ECG as baseline
• Modified 12 lead ECG
• V1-V3 at minus 1 position
• V3-V6 at minus 2 position

Baseline characteristics of patients noted
were Age, Sex, diagnoses, reason for EP lab
visit, medications.
18
Methods Continued

• Data Collection ECG done with same machine, same
  operator
• All ECG will be unidentified and numerically
  coded
• They will be read by EP attending anonymously

19
Preliminary Results

• Surface ECG and modified ECG without significant
  distinction in 100 patients so far.
• Likely to be a negative study

20
References
1. Antzelevitch,C. Yan,G.X. Cellular and ionic
mechanisms responsible for the Brugada syndrome.
J. Electrocardiol. 33 Suppl, 33-39 (2000). 2.
Di Diego,J.M. Antzelevitch,C. Cellular basis
for ST-segment changes observed during ischemia.
J. Electrocardiol. 36 Suppl, 1-5 (2003). 3.
Gussak,I., Antzelevitch,C., Bjerregaard,P.,
Towbin,J.A. Chaitman,B.R. The Brugada syndrome
clinical, electrophysiologic and genetic aspects.
J. Am. Coll. Cardiol. 33, 5-15
(1999). 4. Gussak,I. Antzelevitch,C. Early
repolarization syndrome clinical characteristics
and possible cellular and ionic mechanisms. J.
Electrocardiol. 33, 299-309 (2000). 5.
Gussak,I. et al. ECG phenomenon of idiopathic
and paradoxical short QT intervals. Card
Electrophysiol. Rev. 6, 49-53 (2002). 6.
Kalla,H., Yan,G.X. Marinchak,R. Ventricular
fibrillation in a patient with prominent J
(Osborn) waves and ST segment elevation in the
inferior electrocardiographic leads a Brugada
syndrome variant? J. Cardiovasc. Electrophysiol.
11, 95-98 (2000). 7. Mehta,M., Jain,A.C.
Mehta,A. Early repolarization. Clin. Cardiol. 22,
59-65 (1999). 8. Mehta,M.C. Jain,A.C. Early
repolarization on scalar electrocardiogram. Am.
J. Med. Sci. 309, 305-311 (1995). 9. Shu,J.,
Zhu,T., Yang,L., Cui,C. Yan,G.X. ST-segment
elevation in the early repolarization syndrome,
idiopathic ventricular fibrillation, and the
Brugada syndrome cellular and clinical linkage.
J. Electrocardiol. 38, 26-32 (2005). 10.
Yan,G.X. Antzelevitch,C. Cellular basis for
the electrocardiographic J wave. Circulation 93,
372-379 (1996). 11. Yan,G.X. Antzelevitch,C.
Cellular basis for the Brugada syndrome and other
mechanisms of arrhythmogenesis associated with
ST-segment elevation. Circulation 100, 1660-1666
(1999).