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CLINICAL STUDY: ELECTROPHYSIOLOGIC DISORDERS

ST-segment elevation and ventricular fibrillation without coronary spasm by intracoronary injection of acetylcholine and/or ergonovine maleate in patients with Brugada syndrome

^* Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center, Suita, Japan

Manuscript received April 17, 2002; revised manuscript received June 24, 2002, accepted July 24, 2002.

^* Reprint requests and correspondence: Dr. Wataru Shimizu, Division of Cardiology, Department of Internal Medicine, National Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565 Japan.
wshimizu{at}hsp.ncvc.go.jp

OBJECTIVES: The study examined whether patients with Brugada syndrome are sensitive to vagal stimulation or ischemia.

BACKGROUND: Experimental studies have suggested that a prominent transient outward current (I_to)-mediated action potential notch and a subsequent loss of the action potential dome in the epicardium, but not in the endocardium, give rise to ST-segment elevation and subsequent ventricular fibrillation (VF).

METHODS: We evaluated the frequency of coronary spasm, augmentation (0.1 mV) of ST-segment elevation in leads V₁ to V₃, and induction of VF by intracoronary injection of acetylcholine (ACh) and/or ergonovine maleate (EM) in 27 symptomatic patients with Brugada syndrome and 30 control subjects.

RESULTS: The coronary spasm was induced in 3 (11%) of the 27 patients with Brugada syndrome and in 13 (43%) of the 30 control subjects. ST-segment elevation was augmented by 11 (33%) of the 33 right coronary injections (ACh: 6/11 [55%]; EM: 5/22 [23%]), without coronary spasm, but not by any of the left coronary injections in patients with Brugada syndrome. Ventricular fibrillation was induced by 3 (9%) of the 33 right coronary injections (ACh: 2/11 [18%]; EM: 1/22 [5%]), but not by any of the left coronary injections. In contrast, neither ST-segment elevation nor VF was observed in any of the control subjects.

CONCLUSIONS: Our results support the hypothesis that mild ischemia and vagal influences act additively or synergistically with the substrate responsible for the Brugada syndrome to elevate the ST- segment and precipitate VF. These observations suggest that Brugada patients may be at a higher risk for ischemia-related sudden death.

Abbreviations and Acronyms   ACh   acetylcholine   ECG   electrocardiogram or electrocardiographic   EM   ergonovine maleate   ICa   calcium current   IKATP   adenosine triphosphate–sensitive potassium current   INa   sodium current   Ito   transient outward current   RBBB   right bundle branch block   RVOT   right ventricular outflow tract   VF   ventricular fibrillation

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