La morte improvvisa il ruolo dell extrasistolia. Giuseppe Ricciardi Aritmologia AOU Careggi Firenze

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1 La morte improvvisa il ruolo dell extrasistolia Giuseppe Ricciardi Aritmologia AOU Careggi Firenze

2 Extrasistolia ventricolare in età giovanile 4% 34% 60% 2% TSV Flutter extrasistolia TV

3 Extrasistolia ventricolare in soggetti sani Hingorani P. Journal of Clinical Pharma 2016

4 Incidence and relative risk of sudden death among young athletes and non-athletes from cardiovascular and non-cardiovascular causes Incidence (n/ /year) Athletes Non-athletes Corrado D et al, JACC 2003;42:

5 Incidence and relative risk of sudden death for specific cardiovascular causes among athletes and non-athletes Corrado D et al, JACC 2003;42:

6 Comparison of incidence of underlying heart disease in young athletes dying suddenly in the United States and Italy United States Italy 0 HCM Possible HCM ARVD CAD Cor anomaly Conduct Abn MVP Myocarditis IDCM Other Link MS et al, Curr Opin Cardiol 2001;16:30-39

7 Does sports activity enhance the risk of sudden death in adolescents and young adults? Sports, per se, is not a cause of increased mortality; rather, it acts as a trigger for cardiac arrest in the presence of underlying cardiovascular diseases predisposing to life-threatening ventricular arrhythmias during physical exercise - namely, ARVC, premature CAD, and congenital coronary artery anomaly. Corrado D et al, JACC 2003;42:

8 Extrasistolia e TV idiopatica - sintomi Most patients present with palpitations or presyncope but rarely present with frank syncope. Exercise or emotional stress usually precipitates the tachycardia. Sudden death is rare.

9 Extrasistolia: sintomatologia Mild or absent in many patients; however, in some individuals symptoms are disabling. Palpitations and dizziness frequently be caused by the PVC or the subsequent compensatory pause.

10 Incremento incidenza di scompenso e mortalità in relazione al burden aritmico. Subjects in the highest quartile of PVCS (0.123% to 17.7%) had a three-fold increase in the adjusted risk of left ventricular ejection fraction decline and a 48% and 31% relative risk increase of heart failure and death, respectively, when compared with subjects in the lowest quartile of PVCs (0.0% to 0.002%). Dukes JW, J Am Coll Cardiol 2015;66(2):101 9.

11 Burden aritmico Lee Curr Opin Cardiol 2016, 31:1 10

12 Long term clinical significance of frequent and complex ventricular tachyarrhythmias in trained athletes Biffi A et al, JACC 2002;40:446-52

13 Europace 2017 Apr 1;19(4):

14 Burden aritmico Predictors for the development of PVC-induced cardiomyopathy include a higher burden of PVCs (particularly >20% or more than 20000/day), a longer duration of frequent PVCs, and a wider PVC QRS duration Baman Heart Rhythm 2010;7(7):865 9

15 Recupero della funzione cardiaca dopo ablazione Baman Heart Rhythm 2010;7(7):865 9

16 Impact of QRS duration of frequent premature ventricular complexes on the development of cardiomyopathy QRS duration cutoff value of 150 ms best differentiated patients with and without rpvc-cmp Yokokawa, Heart Rhythm 2012; 9:

17 Extrasistoli ventricolari idiopatiche maligne.

18 Extrasistoli ventricolari idiopatiche maligne. A prematurity index 0.73 has a reported sensitivity of 91% but a specificity of only 44% for identifying malignant PVCs Igarashi JCardiovascElectrophysiol 2012;23:521 6

19 Extrasistoli ventricolari idiopatiche maligne. So called benign PVCs are now known to have malignant potential in susceptible patients and can manifest as triggers for ventricular fibrillation (VF) and sudden cardiac death. Ip, Trends in Cardiovascular Medicine 2018

20 Tanyanan European Heart Journal 2015

21 Assessment of ventricular PVCs -Search for underlying heart desease -Evaluation of morphology/site of origin -Response to exercise testing

22 Battiti ectopici ventricolari EHRA/HRS/APHRS expert consensus on ventricular arrhythmias. Europace 2014;16:

23 Test di inducibilità Japanese Circulation Journal Vol.75, March 2011

24 Quando ricorrere all ablazione In assenza di cardiopatia strutturale Terapia farmacologica sintomatica efficacia 70%-80% terapia cronica effetti collaterali Ablazione transcatetere curativa efficacia 85%-99% complicanze 2-4% recidive 15%-20% Europace (2015) 17,

25 Quando ricorrere all ablazione In presenza di cardiopatia strutturale Europace (2015) 17,

26 Efficacia dell ablazione Ling Circ Arrhythm Electrophysiol. 2014;7:

27 Efficacia dell ablazione Outcomes of catheter ablation in idiopathic ventricular tachycardia Tanyanan European Heart Journal 2015

28 Biffi et all, JACC 44,5;2004

29 Effect of deconditioning on frequent and/or complex ventricular tachyarrhythmias in trained athletes Biffi A et al, JACC 2004;44:

30 Conclusioni L extrasistolia ventricolare è un reperto frequente nella popolazione giovane e nell ambito degli atleti professionisti. L esclusione di una cardiopatia strutturale o di una patologia aritmogena è il principale obiettivo delle indagini cliniche. In assenza di sintomatologia o scompenso cardiaco non vi è indicazione al trattamento dell aritmia. L ablazione è una terapia di elevata efficacia soprattutto in assenza di cardiopatie.