Early ventricular repolarization syndrome

Early ventricular repolarization syndrome has no specific clinical symptoms – it can be detected both in people with heart and vascular pathologies and in those who are absolutely healthy.

To detect the presence of the syndrome, it is necessary to conduct a comprehensive diagnosis, as well as undergo a routine examination by a cardiologist. If you have signs of SRRS, you need to exclude psycho-emotional stress, limit your physical activity, and adjust your diet.

Epidemiology

This is a fairly common disorder - this syndrome can occur in 2-8% of healthy people. With age, the risk of this syndrome decreases. Early ventricular repolarization syndrome is mainly found in people aged 30, but in old age it is quite a rare phenomenon. This disease is mainly observed in people leading an active lifestyle, as well as athletes. Inactive people are not affected by this anomaly. Since the disease has some symptoms similar to Brugada syndrome, it has again attracted the interest of cardiologists.

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Causes of early ventricular repolarization syndrome.

What is dangerous about early ventricular repolarization syndrome? In general, it does not have any characteristic signs, although doctors note that changes in the cardiac conduction system can disrupt the heart rhythm. Severe complications can also occur, such as ventricular fibrillation. In some cases, this can even cause the patient's death.

In addition, this disease often manifests itself against the background of severe vascular and heart diseases or neuroendocrine problems. In children, such combinations of pathological conditions occur most often.

The appearance of premature repolarization syndrome can be provoked by excessive physical exertion. It occurs under the influence of an accelerated electrical impulse that passes through the cardiac conduction system due to the appearance of additional conduction pathways. In general, the prognosis in such cases is favorable, although to eliminate the risk of complications, the load on the heart should be reduced.

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Risk factors

The exact causes of early ventricular repolarization syndrome are currently unknown, although there are some conditions that may be a causative factor in its development:

• Medicines such as a2-adrenergic agonists;
• The blood contains a high percentage of fats;
• Dysplasia appears in connective tissues;
• Hypertrophic cardiomyopathy.

In addition to the above-described signs, a similar anomaly can be observed in those who have heart defects (acquired or congenital) or congenital pathology of the cardiac conduction system.

It is quite possible that the disease has a genetic factor – there are some genes that can contribute to the development of this syndrome.

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Pathogenesis

Scientists assume that the syndrome of early ventricular repolarization is based on the congenital features of the electrophysiological processes occurring in the myocardium of each person. They lead to the appearance of premature repolarization of the subepicardial layers.

The study of pathogenesis allowed to express the opinion that this disorder appears as a result of an anomaly of impulse conduction in the atria and ventricles due to the presence of additional conduction pathways - antegrade, paranodal or atrioventricular. Doctors who studied the problem believe that the notch located on the descending knee of the QRS complex is a delayed delta wave.

The processes of re- and depolarization of the ventricles proceed unevenly. Electrophysiological analysis data showed that the basis of the syndrome is the abnormal chronotopography of the above processes in individual (or additional) structures of the myocardium. They are located in the basal cardiac sections, limited to the space between the anterior wall of the left ventricle and the apex.

Dysfunction of the autonomic nervous system may also cause the syndrome to develop due to the predominance of the sympathetic or parasympathetic divisions. The anterior apical portion may undergo premature repolarization due to increased activity of the sympathetic nerve located on the right. Its branches probably penetrate the anterior cardiac wall and the interventricular septum.

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Symptoms of early ventricular repolarization syndrome.

Early ventricular repolarization syndrome is a medical term and simply means changes in the patient's electrocardiogram. This disorder has no external symptoms. Previously, this syndrome was considered a normal variant, and therefore did not have a negative impact on life.

Various studies have been conducted to determine the characteristic symptoms of early ventricular repolarization syndrome, but no results have been obtained. ECG abnormalities that correspond to this anomaly occur even in completely healthy people who have no complaints. They also occur in patients with cardiac and other pathologies (they complain only of their underlying disease).

Many patients who are diagnosed with early ventricular repolarization syndrome often have a history of the following types of arrhythmias:

• Ventricular fibrillation;
• Supraventricular tachyarrhythmia;
• Ventricular extrasystole;
• Other types of tachyarrhythmias.

Such arrhythmogenic complications of this syndrome can be considered a serious threat to the health, as well as the life of the patient (they can even provoke death). World statistics show many deaths due to asystole in ventricular fibrillation, which appeared precisely because of this anomaly.

Half of those examined with this phenomenon have cardiac dysfunctions (systolic and diastolic), which cause central hemodynamic problems. The patient may develop cardiogenic shock or hypertensive crisis. Pulmonary edema and dyspnea of varying severity may also be observed.

First signs

Researchers believe that the notch that appears at the end of the QRS complex is a delayed delta wave. Additional confirmation of the presence of additional electrical conduction pathways (they become the first cause of the phenomenon) is the reduction of the PQ interval in many patients. In addition, the syndrome of early ventricular repolarization can occur due to an imbalance in the electrophysiological mechanism responsible for the change in the functions of de- and repolarization in different areas of the myocardium, which are located in the basal sections and the cardiac apex.

If the heart is functioning normally, these processes occur in the same direction and in a certain order. Repolarization starts from the epicardium of the cardiac base and ends in the endocardium of the cardiac apex. If a disorder is observed, the first signs are a sharp acceleration in the subepicardial sections of the myocardium.

The development of the pathology is also highly dependent on dysfunctions in the autonomic nervous system. The vagal genesis of the anomaly is proven by conducting a test with moderate physical activity, as well as a drug test with the drug isoproterenol. After this, the patient's ECG indicators stabilize, but the ECG signs worsen during sleep at night.

Early ventricular repolarization syndrome in pregnancy

This pathology is characteristic only when recording electrical potentials on an ECG and in an isolated form does not affect cardiac activity at all, therefore it does not require treatment. It is usually paid attention to only if it is combined with fairly rare forms of severe cardiac arrhythmia.

Numerous studies have confirmed that this phenomenon, especially when accompanied by fainting caused by heart problems, increases the risk of sudden coronary death. In addition, the disease can be combined with the development of supraventricular arrhythmias, as well as a decrease in hemodynamics. All this can ultimately cause heart failure. These factors became the catalyst for the fact that cardiologists became interested in the syndrome.

Early ventricular repolarization syndrome in pregnant women does not affect the pregnancy or the fetus in any way.

Early ventricular repolarization syndrome in children

If your child has been diagnosed with early ventricular repolarization syndrome, the following tests should be performed:

• Taking blood for analysis (vein and finger);
• Average urine sample for analysis;
• Ultrasound examination of the heart.

The above examinations are necessary to exclude the possibility of asymptomatic development of disturbances in the work and conduction of the heart rhythm.

Early ventricular repolarization syndrome in children is not a death sentence, although after its detection it is usually necessary to undergo the process of examining the heart muscle several times. The results obtained after the ultrasound should be taken to a cardiologist. He will determine whether the child has any pathologies in the area of the heart muscles.

This anomaly can be observed in children who had problems with cardiac circulation during the embryonic period. They will need regular check-ups with a cardiologist.

To prevent the child from experiencing attacks of rapid heartbeat, the number of physical activities should be reduced and made less intense. It will not hurt him to follow a proper diet and lead a healthy lifestyle. It will also be useful to protect the child from various stresses.

Forms

Early left ventricular repolarization syndrome is dangerous because in this case there are almost no symptoms of the pathology. Usually this disorder is detected only during an electrocardiogram, where the patient was sent for a completely different reason.

The cardiogram will display the following:

• the P wave changes, indicating that the atria are depolarizing;
• The QRS complex indicates depolarization of the ventricular myocardium;
• The T wave tells about the features of ventricular repolarization - deviations from the norm and are a symptom of a disorder.

From the set of symptoms, the syndrome of premature myocardial repolarization is distinguished. In this case, the process that restores the electric charge is launched ahead of schedule. The cardiogram displays the situation as follows:

• part ST rises from pointer J;
• in the descending region of the R wave, special notches can be seen;
• upward concavity is observed in the background with ST elevation;
• The T wave becomes asymmetrical and narrow.

But it is important to understand that there are many more nuances indicating early ventricular repolarization syndrome. Only a qualified doctor can see them in the ECG results. Only he can prescribe the necessary treatment.

Runner's early ventricular repolarization syndrome

Constant long-term sports activities (at least 4 hours a week) are demonstrated on the ECG as signs that indicate an increase in the volume of the heart chambers, as well as an increase in the tone of the vagus nerve. Such adaptation processes are considered normal, so they do not need to be examined additionally - there is no threat to health.

More than 80% of trained athletes have sinus bradycardia, i.e. a heart rate of less than 60 beats/min. For people in good physical condition, a rate of 30 beats/min is considered normal.

About 55% of young athletes have sinus arrhythmia - the heart rate accelerates when inhaling and slows down when exhaling. This phenomenon is quite normal and should be distinguished from disorders in the sinoatrial node. This can be seen by the electrical axis of the P wave, which remains stable if the body is adapted to the sports load. To normalize the rhythm in this case, a slight decrease in load will be enough - this will eliminate the arrhythmia.

Early ventricular repolarization syndrome was previously defined only by ST elevation, but can now be identified by the presence of a J wave. This finding occurs in approximately 35% to 91% of exercisers and is considered runner's early ventricular repolarization syndrome.

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Complications and consequences

For quite a long time, early ventricular repolarization syndrome was considered a normal phenomenon - doctors did not undertake any treatment when diagnosing it. But in fact, there is a risk that this disorder can cause the development of myocardial hypertrophy or arrhythmia.

If you have been diagnosed with this syndrome, you need to undergo a thorough examination, as it can accompany more serious diseases.

Familial hyperlipidemia, which is characterized by abnormally high levels of lipids in the blood. SRHL is often diagnosed with this disease, although the relationship between the two is not yet clear.

Dysplasia in cardiac connective tissues often occurs in patients with a more pronounced syndrome.

There is a version that this anomaly is also associated with the appearance of obstructive hypertrophic cardiomyopathy (borderline form), since they have similar ECG signs.

Also, SRHR can occur in people with a congenital heart defect or in the presence of anomalies in the cardiac conduction systems.

The disease can cause such consequences and complications as:

• Extrasystole;
• Sinus tachycardia or bradycardia;
• Atrial fibrillation;
• Heart blocks;
• Paroxysmal tachycardia;
• Cardiac ischemia.

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Diagnostics of early ventricular repolarization syndrome.

There is only one reliable way to diagnose early ventricular repolarization syndrome - this is an ECG examination. With its help, you can identify the main signs of this pathology. To make the diagnosis more reliable, you need to register an ECG, using stress tests, and also conduct daily monitoring of the electrocardiogram.

Early ventricular repolarization syndrome on ECG has the following signs:

• the ST segment is shifted by 3+ mm above the isoline;
• the R wave increases, and at the same time the S wave levels out – this shows that the transition region in the chest leads has disappeared;
• at the end of the R-wave particle a pseudo-r-wave appears;
• the QRS complex becomes longer;
• the electric axis moves to the left;
• high T-waves with asymmetry are observed.

Basically, in addition to the usual ECG examination, a person undergoes ECG registration using additional loads (physical or using medications). This allows us to find out what the dynamics of the disease symptoms are.

If you are going to visit a cardiologist again, bring with you the results of previous ECGs, because any changes (if you have this syndrome) can cause an acute attack of coronary insufficiency.

Tests

Often, early ventricular repolarization syndrome is detected in a patient by chance – during an ECG test. Apart from the changes recorded by this device, when a person’s cardiovascular system is in order, this syndrome has no signs in most cases. And the subjects themselves have no complaints about their health.

The examination includes the following tests:

• An exercise test in which there are no signs of disease on the ECG;
• Potassium challenge: A patient with the syndrome takes potassium (2g) to make the symptoms more severe;
• Use of novocainamide - it is administered intravenously so that signs of anomaly are clearly visible on the ECG;
• 24-hour ECG monitoring;
• Taking a biochemical blood test, as well as the results of a lipidogram.

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Instrumental diagnostics

Early ventricular repolarization syndrome can only be detected by ECG and in no other way. This disease has no specific clinical symptoms, so it can be found even in a completely healthy person. Although in some cases the syndrome can accompany certain diseases, for example, neurocirculatory dystonia. This phenomenon was first identified and described in 1974.

When conducting instrumental diagnostics, an electrocardiogram is used, as indicated above. In this case, the main sign of the presence of this syndrome in a person is a change in the RS-T segment - an increase from the isoelectric line upwards is observed.

The next symptom is the appearance of a specific notch, which is called the "transition wave" on the descending knee of the R-wave. This notch may also appear on the top of the ascending S-wave (similar to r'). This is a rather important sign for differentiation, because an isolated upward rise of the RS-T particle can also be observed in serious severe diseases. Among them are the acute stage of myocardial infarction, acute pericarditis and the so-called Prinzmetal's angina. Therefore, when making a diagnosis, you need to be very careful, and, if necessary, prescribe a more in-depth examination.

ECG signs

Early ventricular repolarization syndrome does not have any specific clinical symptoms. It can be noticed only as some changes in the electrocardiogram readings. These are the following signs:

• The T wave and ST particle change shape;
• In some branches, the ST segment rises above the isoline by 1-3 mm;
• Often the ST segment begins to rise after the notch;
• The ST particle has a rounded shape, which then transitions directly into a tall T-wave with a positive value;
• The convexity of the ST particle is directed downwards;
• The T wave has a broad base.

The ECG signs of anomaly are most noticeable in the chest leads. The ST segment rises above the isoline, having a downward convexity. The sharp T-wave has a high amplitude and in some cases can be inverted. The J-junction point is located high on the descending knee of the R-wave or on the last part of the S-wave. A notch that appears at the site of the change from the S-wave to the descending part of the ST can cause the formation of an r´ wave.

If the S wave has diminished or disappeared completely from the left chest leads (marks V5 and V6), this demonstrates a counterclockwise rotation of the heart along the longitudinal axis. In this case, a QRS complex of the qR type is formed in the V5 and V6 areas.

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Differential diagnosis

This syndrome can accompany a variety of diseases and be caused by various reasons. When performing an examination, it can be confused with such diseases as hyperkalemia and arrhythmogenic dysplasia in the right ventricle, pericarditis, Brugada syndrome, as well as electrolyte imbalances. All these factors make you pay attention to this anomaly - consult a cardiologist and undergo a comprehensive examination.

Differential diagnostics are carried out in order to:

• To exclude the possibility of acute disturbance in the inferior wall of the left ventricle;
• To exclude the possibility of acute damage in the anterior lateral wall of the left ventricle.

This phenomenon can cause signs of coronary syndrome (acute form) to appear on the electrocardiogram. In this case, differential diagnostics can be carried out on the following grounds:

• The clinical picture typical of coronary heart disease is absent;
• In the terminal part of the QRS complex with the presence of a notch, a characteristic shape is observed;
• The ST segment takes on a peculiar appearance;
• When performing a functional ECG test using physical exercise, the ST segment is often close to the baseline.

Early ventricular repolarization syndrome must be differentiated from Brugada syndrome, myocardial infarction (or coronary syndrome when the ST segment is elevated), pericarditis, and arrhythmogenic dysplasia in the right ventricle.

In case of myocardial infarction, in addition to the clinical picture, it will be very important to conduct a dynamic ECG examination, as well as to determine the level of markers (troponin and myoglobin) of myocardial destruction. There are cases when, in order to clarify the diagnosis, it is necessary to perform coronary angiography.

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Treatment of early ventricular repolarization syndrome.

People who have been diagnosed with early ventricular repolarization syndrome should avoid intense sports and physical activity in general. You should also adjust your diet - add foods that contain magnesium and potassium, as well as vitamin B (these are raw fruits and vegetables, greens, nuts, soy products, sea fish).

Treatment of early ventricular repolarization syndrome is performed using an invasive method - the additional bundle is subjected to radiofrequency ablation. Here, the catheter is brought to the location of this bundle and it is eliminated.

This syndrome can cause acute coronary syndrome, so it is important to find the cause of problems with heart activity and heart valves in a timely manner. Acute coronary syndrome can cause sudden death.

If the patient is diagnosed with concomitant life-threatening arrhythmias or pathologies, he may be prescribed a course of drug therapy - it will prevent the development of health-threatening complications. There are also cases when the patient is prescribed surgical treatment.

Medicines

Often, when early ventricular repolarization syndrome is detected, no drug therapy is prescribed, but if the patient also has symptoms of any cardiac pathology (this could be one of the forms of arrhythmia or coronary syndrome), he will need to undergo a course of specific drug treatment.

Multiple random studies have shown that energy-tropic therapy medications are very good for eliminating the symptoms of this pathology – they are suitable for both adults and children. Of course, this group of drugs does not directly relate to the syndrome, but they help improve the trophism of the heart muscle, as well as eliminate possible complications in its work. The syndrome is best treated with the following energy-tropic drugs: Kudesan, the dose of which is 2 mg / 1 kg per day, Carnitine 500 mg twice a day, Neurovitan 1 pill per day and a vitamin complex (group B).

Antiarrhythmic drugs may also be prescribed. They are capable of slowing down the repolarization process. Among such drugs are Novocainamide (dosage of 0.25 mg every 6 hours), Quinidine sulfate (three times a day, 200 mg), Ethmozin (three times a day, 100 mg).

Vitamins

If a patient is diagnosed with early ventricular repolarization syndrome, he or she may be prescribed B vitamins, medications that include magnesium and phosphorus, and carnitine.

To keep your heart healthy, you need to follow a balanced diet and meet your body's need for beneficial microelements and vitamins.

Physiotherapy, as well as homeopathy, herbal treatments and folk remedies are not used to treat early ventricular repolarization syndrome.

Surgical treatment

Early ventricular repolarization syndrome can be treated radically – with the help of surgical intervention. But it should be understood that this method is not used if the patient has an isolated form of the disease. It can be used only if there are clinical symptoms of moderate or severe intensity or if there is a deterioration in health.

If additional conduction pathways are found in the myocardium or the SRHR has some clinical signs, the patient is prescribed a radiofrequency ablation procedure, which destroys the source of the arrhythmia. If the patient has life-threatening heart rhythm disturbances or loses consciousness, doctors can implant a pacemaker.

Surgical treatment can be used if a patient with the syndrome has frequent attacks of ventricular fibrillation - a so-called defibrillator-cardioverter is implanted. Thanks to modern microsurgical techniques, such a device can be installed without thoracotomy, using a minimally invasive method. Third-generation cardioverter-defibrillators are well tolerated by patients, without causing rejection. Now this method is considered the best for treating arrhythmogenic pathologies.

Prevention

Early ventricular repolarization syndrome cannot be prevented because the exact cause of its occurrence has not yet been identified. Prevention is also impossible because the anomaly can manifest itself not only in people suffering from heart pathologies, but also in those who do not have health problems.

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Forecast

Numerous studies have proven that this phenomenon has an optimistic prognosis, although there are some nuances.

This syndrome cannot be considered completely benign, however, since it can sometimes become a substrate for sudden cardiac death, ventricular arrhythmias, and athletes may develop hypertrophic cardiomyopathy.

Athletes with syncope should be carefully monitored after exercise. If arrhythmias have life-threatening symptoms, patients should be implanted with an ICD.

Early Ventricular Repolarization Syndrome and the Army

This pathology is not a reason for banning military service; conscripts with such a diagnosis undergo a medical examination and receive a verdict of “fit for service”.

The syndrome itself can become one of the factors of segment elevation (non-ischemic nature).

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