Long QT syndrome! Should we treat all asymptomatic patients?!
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1 ! Long QT syndrome! Should we treat all asymptomatic patients?! Venice Arrhythmia 2015! Arthur A.M. Wilde Heart Centre
2 NO CONFLICT OF INTEREST TO DECLARE
3 Long QT Syndrome(s) Autosomal dominant/autosomal rec. genetically heterogeneous 16 genes (LQTS ) % genotyped ( 90% in families) gene-specific features Heart Centre
4 Risk of syncope/aca/scd in LQTS population:! (age 1 through 75 yrs) Moss and Goldenberg JACC % 8% Before puberty LQT1 (males), after puberty LQT2 (females)?
5 Long QT syndrome, risk stratification Established risk factors Aborted sudden death Syncope congenital deafness (JLN) Torsades de Pointes, T-wave alternans Prolonged QT (> 500ms) Family history of (a)scd not Heart Centre
6 Congenital LQTS Symptomatology Heart Centre
7 Long QT syndrome, risk stratification Established risk factors Aborted sudden death Syncope congenital deafness (JLN) Torsades de Pointes, T-wave alternans Prolonged QT (> 500ms) Family history of (a)scd not Heart Centre
8 Long QT syndrome, risk stratification Established risk factors, Asymptomatic pts Aborted sudden death Syncope congenital deafness (JLN) Torsades de Pointes, T-wave alternans Prolonged QT (> 500ms) Family history of (a)scd not Heart Centre
9 A patient at risk Neonate, prenatal bradycardia, hydrops, syndactyly. Courtesy Dr Nico Blom
10 Jervell Lange-Nielsen Syndrome Female 6y old, syncopal attacks, sensorinal bilateral deafness
11 Long QT syndrome, risk stratification QT C Quartiles: 1: 446 ms 2: ms 3: ms 4: 499 ms NEJM 2003;348: ardiologie
12 Long QT syndrome, role of genetics Genetic real estate : Transmembrane LQTS2 mutations Missense LQTS1 mutations Specific LQTS1 mutations (e.g. A341V) Large variation in LQT3 Heart Centre
13 Heart Centre
14 14 LQTS1&2
15 Heart Centre
16 QTc 440ms QTc > 441ms
17 Long QT Syndrome Class Class I Class IIa Class III ICD Recommendations ICD implantation is recommended for patients with a diagnosis of LQTS who are survivors of a cardiac arrest IICD implantation can be useful in patients with a diagnosis of LQTS who experience recurrent syncopal events while on beta-blocker therapy. Except under special circumstances, ICD implantation is not indicated in asymptomatic LQTS patients who have not been tried on betablocker therapy Family history is NOT a risk factor Heart Centre
18 Long QT syndrome, asymptomatic pt When should an ICD be considered? JLNS patient with a long QTc (>500msec) LQT2 pt with QTc > 550 LQT3 pt with QTc > 500 Torsades de Pointes, T-wave alternans rarely LQT1! Family history of (a)scd is not a riskfactor Heart Centre
19 Class Class I Class IIa Beta-blocker Recommendations Beta-blockers are recommended for patients with a diagnosis of LQTS who are: Asymptomatic with QTc > 470 ms, and/or Symptomatic for syncope or documented VT/VF. Beta-blockers can be useful in patients with a diagnosis of LQTS who are asymptomatic with QTc < 470ms But in who treatment is not needed? Heart Centre
20 Long QT syndrome, focus on LQT1
21 Long QT syndrome, focus on LQT1 Moss, Shimizu, Wilde et al. Circulation 2007 Heart Centre
22 Long QT syndrome, focus on LQT1 KCNQ1 A341V versus other KCNQ1 mutations Crotti et al, Circulation 2007 Heart Centre
23 Circulation 2002;105:794-9 Mutation dependent prognosis (LQTS2) LQTS2
24 Class Class I Class IIa Beta-blocker Recommendations Beta-blockers are recommended for patients with a diagnosis of LQTS who are: Asymptomatic with QTc > 470 ms, and/or Symptomatic for syncope or documented VT/VF. Beta-blockers can be useful in patients with a diagnosis of LQTS who are asymptomatic with QTc < 470ms Low risk: asymptomatic LQT1 adult (QTc < 500?) Heart Centre
25 Class Class I Class IIa Beta-blocker Recommendations Beta-blockers are recommended for patients with a diagnosis of LQTS who are: Asymptomatic with QTc > 470 ms, and/or Symptomatic for syncope or documented VT/VF. Beta-blockers can be useful in patients with a diagnosis of LQTS who are asymptomatic with QTc < 470ms Low risk: asymptomatic LQT1 adult (QTc < 500?) Heart Centre
26 (Circulation 2008;117: )
27 Figure 1. Kaplan Meier estimates of the probability of ACA or SCD by gender (values in parentheses are event rates). Goldenberg I et al. Circulation 2008;117: Copyright American Heart Association
28 Figure 2. Kaplan Meier estimates of the probability of ACA or SCD by gender and QTc subgroups (values in parentheses are event rates). LQTS1 Goldenberg I et al. Circulation 2008;117: Copyright American Heart Association
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34 20 years cardiogenetics in the Netherlands Amsterdam, the Netherlands December 4th 2015 For information and registration see Organising committee: Karin Y. van Spaendonck J. Peter van Tintelen Arthur Wilde
35 Thank you
36 Mutations sites in the KCNQ1 gene PKA Downloaded from at LONDON HEALTH SCIENCES CENTER on March 29, 2012 Beta Adrenergic Barsheshet ea, Circulation. 2012;125:
37 JAMA 2006;296:
38 Risk during adolescence (10-20y) 2772 children followed between 10 and 20y 81 ACA and 45 SCD (4,5%) risk factors: syncope, QTc and gender (10-12) JAMA 2006;296:
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40 Does the genotype matter? LQTS 2 LQTS 3 LQTS 1
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sudden cardiac death, torsades de pointes, T wave alternans, syncope, genetic mutation
Reprinted with permission from JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY Volume 12 No. 4 April 2001 Copyright 2001 by Futura Publishing Company Inc. Armonk NY 10504-0418 Electrocardiographic Prediction
How do you decide on rate versus rhythm control?
How do you decide on rate versus rhythm control? Dr. Mark O Neill Consultant Cardiologist & Electrophysiologist Assumptions Camm et al. EHJ 2010;Sept 25 epub Choice of strategy: Criteria for consideration
Syncope. enough to include disorders such as epileptic seizures and concussion. January 14-15, 2011 SCA Conference 1
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RATE VERSUS RHYTHM CONTROL OF ATRIAL FIBRILLATION: SPECIAL CONSIDERATION IN ELDERLY. Charles Jazra
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Below, this letter outlines [patient name] s medical history, prognosis, and treatment rationale.
![Below, this letter outlines [patient name] s medical history, prognosis, and treatment rationale.](/thumbs/25/5563775.jpg "Below, this letter outlines [patient name] s medical history, prognosis, and treatment rationale.")
[Date] [Name of Contact] [Title] [Name of Health Insurance Company] [Address] [City, State, Zip Code] Insured: [Patient Name] Policy Number: [Number] Group Number: [Number] Diagnosis: [Diagnosis and ICD-9-CM