https://en.ecgpedia.org/api.php?action=feedcontributions&user=77.251.13.40&feedformat=atomECGpedia - User contributions [en]2024-03-29T11:03:57ZUser contributionsMediaWiki 1.39.5https://en.ecgpedia.org/index.php?title=Approach_to_the_Wide_Complex_Tachycardia&diff=11073Approach to the Wide Complex Tachycardia2010-11-06T16:03:17Z<p>77.251.13.40: /* Ultrasimple Brugada criterion */</p>
<hr />
<div>During wide complex tachycardia (heart rate > 100/min, QRS > 0.12 sec) the differentiation between supraventricular and ventricular origin of the arrhythmia is important to guide therapy. Several algorithms have been developed to aid in this differentiation (below). It is important to keep in mind that a good estimate of VT ''versus'' SVT can be made based on the clinical vignette:<br />
* 'Horizontal entrance' into the ER. Older patient with previous myocardial infarction = most likely VT<br />
* Younger patient with known paroxysmal tachycardias and who is hemodynamically stable = most like SVT<br />
== The ACC algorithm <cite>ACC</cite>==<br />
[[File:VT_algorythm_en.png|800px|thumb|left|SVT vs VT algorhytm. Adapted from <cite>ACC</cite>]]<br />
{{clr}}<br />
<br />
== Brugada criteria ==<br />
[[File:Brugada_algorithm.png|500px|thumb|left]]<br />
<br />
{| class="wikitable" width="500px"<br />
! colspan="3" | Morphological criteria (if the above criteria are inconclusive)<br />
|-<br />
!colspan="3" |[[LBBB]] pattern<br />
|-<br />
| Initial R more than 40ms? ||Yes => VT || [[Image:Rhythm_RSratio.png|thumb|100px]]<br />
|-<br />
| Slurred or notched downwards leg of S wave in leads V1 or V2 || Yes => [[VT]] ||<br />
|-<br />
| Beginning of Q to nadir QS >60 ms in V1 or V2? || Yes => [[VT]] || LR >50:1<br />
|-<br />
| Q or QS in V6? || Yes => [[VT]] || LR >50:1<br />
|-<br />
| colspan="3" |[[Image:Rhythm_LBTBmorph_nl.png|thumb|300px]]<br />
|-<br />
! colspan="3" |[[RBBB]] pattern<br />
|-<br />
| Monofasic R or qR in V1? ||Yes => [[VT]] ||<br />
|-<br />
| R taller than R' (rabbit-ear sign)?||Yes => [[VT]] || LR >50:1<br />
|-<br />
| rS in V6? || Yes => VT || LR >50:1<br />
|-<br />
| colspan="3" |[[Image:Rhythm_RBTBmorph_nl.png|thumb|300px]]<br />
|-<br />
|}<br />
{{clr}}<br />
== Ultrasimple Brugada criterion ==<br />
[[File:RWPT.svt|thumb|right|300px|R-wave to Peak Time ≥ 50ms in lead II strongly suggests VT]]In 2010 Joseph Brugada et al. published a new criterion to differentiate VT from SVT in wide complex tachycardias: the R wave peak time in Lead II <cite>Brugada2</cite>. They suggest measuring the duration of onset of the QRS to the first change in polarity (either nadir Q or peak R) in lead II. If the RWPT is ≥ 50ms the likelihood of a VT very high (positive likelihood ratio 34.8). This criterion was successful in their own population of 163 selected patients and is awaiting prospective testing in a larger trial.<br />
<br />
== Vereckei algorithm <cite>Vereckei</cite>==<br />
[[File:Vereckei_algorithm.png|500px|thumb|left]]<br />
[[File:vivt.png|300px|thumb|If the distance traveled on the Y axis in the initial 40ms of the QRS complex is smaller than that traveled in the terminal 40ms of the QRS complex, a VT is much more likely]]<br />
{{clr}}<br />
<br />
==Examples==<br />
<gallery><br />
Image:wide_qrs_tachy_AAM1.jpg|Wide complex tachycardia. No AV dissociation. RBBB. Resembles sinus rhythm from the same patient. Conclusion: SVT with [[RBBB]]<br />
Image:wide_qrs_tachy_AAM2.jpg|ECG from the same patient in sinus rhythm. The QRS complex is very similiar.<br />
Image:wide_qrs_tachy_AAM3.png|Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. [[AV dissociation]] is present. Conclusion: [[VT]]<br />
Image:wide_qrs_tachy_AAM4.png|Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. [[AV dissociation]] is present. Conclusion: [[VT]]<br />
</gallery><br />
== Referenties ==<br />
<biblio><br />
#ACC pmid=14563598<br />
#Brug1 pmid=2022022<br />
#Vereckei pmid=17272358<br />
#Brugada2 pmid=20215043 <br />
</biblio></div>77.251.13.40https://en.ecgpedia.org/index.php?title=Arrhythmogenic_Right_Ventricular_Cardiomyopathy&diff=11038Arrhythmogenic Right Ventricular Cardiomyopathy2010-09-17T20:51:23Z<p>77.251.13.40: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|advisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= P.G. Postema, MD<br />
}}<br />
[[Image:epsilon_wave.png|thumb|ECG with an epsilon wave in V1]]<br />
[[Image:arvdhart.png|thumb| A section throughout the heart of an ARVC patient. (A) Transmural fatty replacement of the right ventricular free wall. (B) Myocardial atrophy is confined to the right ventricle and substantially spares the interventricular septum as well as the left ventricular free wall. <cite>Corrado</cite> Reproduced with permission from BMJ Publishing Group Ltd. ]]<br />
'''Arrhythmogenic Right Ventricular Cardiomyopathy''', (ARVC, or ARVD: Arrhythmogenic Right Ventricular Disease) is characterized by fatty replacement and fibrosis of the heart. Most commonly the right ventricle apex and outflow tract are involved. However the left ventricle can be affected to.<cite>Corr</cite><br />
<br />
As a result of the fatty replacement and fibrosis, ventricular arrhythmias are common in this disease and can lead to palpitations, syncope and sudden death. At more advanced ages right ventricular pump failure can occur.<br />
<br />
The diagnosis is based on major and minor criteria, as published by the European Society of Cardiology.<cite>McKenna1994</cite><br />
<br />
ARVC is a progressive disease. The '''incidence''' is estimated to be 1:3.000-1:10.000. Manifestations are usually seen in teenagers. Although the diagnosis is more often made in athletes, sports are not thought to have a causative relationship with the disease. ARVD can occur in families; more than 9 different chromosomal defects have been described, most often with autosomal dominant inheritance. <br />
<br />
One unique form of ARVD, called Naxos disease (after the Greek island where it was first diagnosed), has an autosomal recessive pattern of inheritance. <br />
<br />
'''Diagnosis''' ARVC is a difficult diagnosis to make. Therefore, the European Society of Cardiology has created a list of diagnostic criteria for the diagnosis of ARVC<cite>#McKenna1994</cite> (see table).<br />
{| class="wikitable" width="400px"<br />
!Major diagnostic criteria for Arrhythmogenic Right Ventricular Cardiomyopathy<cite>McKenna1994</cite><br />
|-<br />
|<ul><li>Familial disease confirmed at necroscopy or surgery</li><br />
<li>Severe dilatation and reduction of right ventricular ejection fraction with no (or only mild) LV impairment</li><br />
<li>Localized right ventricular aneurysms (akinetic or diskinetic areas with diastolic bulging)</li><br />
<li>Severe segmental dilataion of the right ventricle</li><br />
<li>Fibrofatty replacement of myocardium on endomyocardial biopsy</li><br />
</ul><br />
|-<br />
!Diagnostic criteria that can be diagnosed on the ECG<br />
|-<br />
|<ul><br />
<li>(major) Epsilon wave or localized prolongation (>110ms) of the QRS complex in right precordial leads (V1-V3)</li><br />
<li>(minor) Inverted T waves in right precordial leads (V2 and V3) (people aged more than 12 yr; in absence of [[RBBB]]</li><br />
<li>(minor) [[Late potentials]] ([[SAECG|signal averaged ECG]])</li><br />
<li>(minor) Left bundle branch block type [[Ventricular Tachycardia|ventricular tachycardia]] (sustained and non-sustained) (ECG, [[Holter]], [[Exercise Testing|exercise testing]]</li><br />
<li>(minor) Frequent [[Ventricular Premature Beats|ventricular extrasystoles]] (more than 1000/24h) ([[Holter]])</li><br />
</ul><br />
|}<br />
In 2009 these criteria were updated<cite>cox</cite><cite>Crit2010</cite>, see the table below.<br />
<br />
'''Treatment''' focuses on avoiding complications.<cite>ACC2006</cite><br />
*Medication: <br />
**Anti-arrhythmics: Sotalol better than Amiodarone.<br />
**ACE-inhibitors to prevent cardiac remodelling<br />
*[[ICD]] implantation is recommended for the prevention of sudden cardiac death in patients with ARVC with documented sustained VT or VF who are receiving chronic optimal medical therapy.<br />
*[[ICD]] implantation can be considered for the prevention of sudden cardiac death in patients with ARVC with extensive disease, including those with left ventricular involvement, 1 or more affected family member with SCD (Sudden Cardiac Death), or undiagnosed syncope when [[Ventricular Tachycardia|ventricular tachycardia]] or [[Ventricular Fibrillation|ventricular Fibrillation]] has not been excluded as the cause of syncope, who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y.<br />
*Radiofrequency [[ablation]] can be useful as adjunctive therapy in management of patients with ARVC with recurrent [[Ventricular Tachycardia|ventricular tachycardia]], despite optimal antiarrhythmic drug therapy.<br />
<br />
<gallery><br />
Image:arvd_ecg1.png<br />
Image:arvd_ecg2.png<br />
Image:arvd_ecg3.png<br />
</gallery><br />
<br />
== Revised Task Force Criteria ARVD / ARVC==<br />
{| class="wikitable"<br />
|+ Comparison of Original and Revised Task Force Criteria<br />
! style="width:500px" | Original Task Force Criteria<br />
! style="width:500px" | Revised Task Force Criteria<br />
|-<br />
| colspan="2" | '''I. Global or regional dysfunction and structural alterations<sup>&lowast;</sup>'''<br />
|-<br />
| colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
| valign="top" style="padding-left:24px" |<br />
* Severe dilatation and reduction of RV ejection fraction with no (or only mild) LV impairment<br />
* Localized RV aneurysms (akinetic or dyskinetic areas with diastolic bulging)<br />
* Severe segmental dilatation of the RV<br />
| valign="top" |<br />
<strong>By 2D echo:</strong><br />
* Regional RV akinesia, dyskinesia, or aneurysm<br />
* and 1 of the following (end diastole):<br />
** PLAX RVOT &ge;32 mm (corrected for body size [PLAX/BSA] &ge;19 mm/m<sup>2</sup>)<br />
** PSAX RVOT &ge;36 mm (corrected for body size [PSAX/BSA] &ge;21 mm/m<sup>2</sup>)<br />
** <em>or</em> fractional area change &le;33%<br />
<strong>By MRI:</strong><br />
* Regional RV akinesia or dyskinesia or dyssynchronous RV contraction<br />
* <em>and</em> 1 of the following:<br />
** Ratio of RV end-diastolic volume to BSA &ge;110 mL/m<sup>2</sup> (male) or &ge;100 mL/m<sup>2</sup> (female)<br />
** <em>or</em> RV ejection fraction &le;40%<br />
<strong>By RV angiography:</strong><br />
* Regional RV akinesia, dyskinesia, or aneurysm<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
| valign="top" style="padding-left:24px" |<br />
* Mild global RV dilatation and/or ejection fraction reduction with normal LV<br />
* Mild segmental dilatation of the RV<br />
* Regional RV hypokinesia<br />
| valign="top" |<br />
<strong>By 2D echo:</strong><br />
* Regional RV akinesia or dyskinesia<br />
* <em>and</em> 1 of the following (end diastole):<br />
** PLAX RVOT &ge;29 to &lt;32 mm (corrected for body size [PLAX/BSA] &ge;16 to &lt;19 mm/m<sup>2</sup>)<br />
** PSAX RVOT &ge;32 to &lt;36 mm (corrected for body size [PSAX/BSA] &ge;18 to &lt;21 mm/m<sup>2</sup>)<br />
** <em>or</em> fractional area change &gt;33% to &le;40%<br />
<strong>By MRI:</strong><br />
* Regional RV akinesia or dyskinesia or dyssynchronous RV contraction<br />
* <em>and</em> 1 of the following:<br />
** Ratio of RV end-diastolic volume to BSA &ge;100 to &lt;110 mL/m<sup>2</sup> (male) or &ge;90 to &lt;100 mL/m<sup>2</sup> (female)<br />
** <em>or</em> RV ejection fraction &gt;40% to &le;45%<br />
|-<br />
| colspan="2" | '''II. Tissue characterization of wall'''<br />
|-<br />
| colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
| valign="top" style="padding-left:24px" |<br />
* Fibrofatty replacement of myocardium on endomyocardial biopsy<br />
|<br />
* Residual myocytes &lt;60% by morphometric analysis (or &lt;50% if estimated), with fibrous replacement of the RV free wall myocardium in &ge;1 sample, with or without fatty replacement of tissue on endomyocardial biopsy<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
|<br />
| valign="top" |<br />
* Residual myocytes 60% to 75% by morphometric analysis (or 50% to 65% if estimated), with fibrous replacement of the RV free wall myocardium in &ge;1 sample, with or without fatty replacement of tissue on endomyocardial biopsy<br />
|-<br />
| colspan="2" | '''III. Repolarization abnormalities'''<br />
|-<br />
|'''Bold text''' colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
| &nbsp;<br />
|<br />
* Inverted T waves in right precordial leads (V<sub>1</sub>, V<sub>2</sub>, and V<sub>3</sub>) or beyond in individuals &gt;14 years of age (in the absence of complete right bundle-branch block QRS &ge;120 ms)<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
| valign="top" style="padding-left:24px" |<br />
* Inverted T waves in right precordial leads (V<sub>2</sub> and V<sub>3</sub>) (people age &gt;12 years, in absence of right bundle-branch block)<br />
|<br />
* Inverted T waves in leads V<sub>1</sub> and V<sub>2</sub> in individuals &gt;14 years of age (in the absence of complete right bundle-branch block) or in V<sub>4</sub>, V<sub>5</sub>, or V<sub>6</sub><br />
* Inverted T waves in leads V<sub>1</sub>, V<sub>2</sub>, V<sub>3</sub>, and V<sub>4</sub> in individuals &gt;14 years of age in the presence of complete right bundle-branch block<br />
|-<br />
| colspan="2" | '''IV. Depolarization/conduction abnormalities'''<br />
|-<br />
| colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
| style="padding-left:24px" |<br />
* Epsilon waves or localized prolongation (&gt;110 ms) of the QRS complex in right precordial leads (V<sub>1</sub> to V<sub>3</sub>)<br />
|<br />
* Epsilon wave (reproducible low-amplitude signals between end of QRS complex to onset of the T wave) in the right precordial leads (V<sub>1</sub> to V<sub>3</sub>)<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
| style="padding-left:24px" valign="top" |<br />
* Late potentials (SAECG)<br />
|<br />
* Late potentials by SAECG in &ge;1 of 3 parameters in the absence of a QRS duration of &ge;110 ms on the standard ECG<br />
* Filtered QRS duration (fQRS) &ge;114 ms<br />
* Duration of terminal QRS &lt;40 <em>&micro;</em>V (low-amplitude signal duration) &ge;38 ms<br />
* Root-mean-square voltage of terminal 40 ms &le;20 <em>&micro;</em>V<br />
* Terminal activation duration of QRS &ge;55 ms measured from the nadir of the S wave to the end of the QRS, including R&acute;, in V<sub>1</sub>, V<sub>2</sub>, or V<sub>3</sub>, in the absence of complete right bundle-branch block<br />
|-<br />
| colspan="2" | '''V. Arrhythmias'''<br />
|-<br />
| colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
|<br />
|<br />
* Nonsustained or sustained ventricular tachycardia of left bundle-branch morphology with superior axis (negative or indeterminate QRS in leads II, III, and aVF and positive in lead aVL)<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
| style="padding-left:24px" valign="top" |<br />
* Left bundle-branch block–type ventricular tachycardia (sustained and nonsustained) (ECG, Holter, exercise)<br />
* Frequent ventricular extrasystoles (&gt;1000 per 24 hours) (Holter)<br />
|<br />
* Nonsustained or sustained ventricular tachycardia of RV outflow configuration, left bundle-branch block morphology with inferior axis (positive QRS in leads II, III, and aVF and negative in lead aVL) or of unknown axis<br />
* &gt;500 ventricular extrasystoles per 24 hours (Holter)<br />
|-<br />
| colspan="2" | '''VI. Family history'''<br />
|-<br />
| colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
| style="padding-left:24px" valign="top" |<br />
* Familial disease confirmed at necropsy or surgery<br />
|<br />
* ARVC/D confirmed in a first-degree relative who meets current Task Force criteria<br />
* ARVC/D confirmed pathologically at autopsy or surgery in a first-degree relative<br />
* Identification of a pathogenic mutation<sup>&dagger;</sup> categorized as associated or probably associated with ARVC/D in the patient under evaluation<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
| style="padding-left:24px" valign="top" |<br />
* Family history of premature sudden death (&lt;35 years of age) due to suspected ARVC/D<br />
* Familial history (clinical diagnosis based on present criteria)<br />
|<br />
* History of ARVC/D in a first-degree relative in whom it is not possible or practical to determine whether the family member meets current Task Force criteria<br />
* Premature sudden death (&lt;35 years of age) due to suspected ARVC/D in a first-degree relative<br />
* ARVC/D confirmed pathologically or by current Task Force Criteria in second-degree relative<br />
|-<br />
| colspan="2" |<br />
<ul><br />
<li>PLAX indicates parasternal long-axis view; RVOT, RV outflow tract; BSA, body surface area; PSAX, parasternal short-axis view; aVF, augmented voltage unipolar left foot lead; and aVL, augmented voltage unipolar left arm lead.</li><br />
<li>Diagnostic terminology for original criteria: This diagnosis is fulfilled by the presence of 2 major, or 1 major plus 2 minor criteria or 4 minor criteria from different groups. Diagnostic terminology for revised criteria: definite diagnosis: 2 major or 1 major and 2 minor criteria or 4 minor from different categories; borderline: 1 major and 1 minor or 3 minor criteria from different categories; possible: 1 major or 2 minor criteria from different categories.</li><br />
<li><sup>&lowast;</sup> Hypokinesis is not included in this or subsequent definitions of RV regional wall motion abnormalities for the proposed modified criteria.</li><br />
<li><sup>&dagger;</sup> A pathogenic mutation is a DNA alteration associated with ARVC/D that alters or is expected to alter the encoded protein, is unobserved or rare in a large non–ARVC/D control population, and either alters or is predicted to alter the structure or function of the protein or has demonstrated linkage to the disease phenotype in a conclusive pedigree.</li><br />
</ul><br />
|}<br />
<br />
==References==<br />
<biblio><br />
#McKenna1994 pmid=8142187<br />
#Corrado pmid=10768917<br />
#ACC2006 pmid=16949478<br />
#Corr pmid=19366719<br />
#cox pmid=20215590<br />
#Crit2010 pmid=20172912<br />
</biblio></div>77.251.13.40https://en.ecgpedia.org/index.php?title=Arrhythmogenic_Right_Ventricular_Cardiomyopathy&diff=11037Arrhythmogenic Right Ventricular Cardiomyopathy2010-09-17T20:49:36Z<p>77.251.13.40: /* References */</p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|advisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= P.G. Postema, MD<br />
}}<br />
[[Image:epsilon_wave.png|thumb|ECG with an epsilon wave in V1]]<br />
[[Image:arvdhart.png|thumb| A section throughout the heart of an ARVC patient. (A) Transmural fatty replacement of the right ventricular free wall. (B) Myocardial atrophy is confined to the right ventricle and substantially spares the interventricular septum as well as the left ventricular free wall. <cite>Corrado</cite> Reproduced with permission from BMJ Publishing Group Ltd. ]]<br />
'''Arrhythmogenic Right Ventricular Cardiomyopathy''', (ARVC, or ARVD: Arrhythmogenic Right Ventricular Disease) is characterized by fatty replacement and fibrosis of the heart. Most commonly the right ventricle apex and outflow tract are involved. However the left ventricle can be affected to.<cite>Corr</cite><br />
<br />
As a result of the fatty replacement and fibrosis, ventricular arrhythmias are common in this disease and can lead to palpitations, syncope and sudden death. At more advanced ages right ventricular pump failure can occur.<br />
<br />
The diagnosis is based on major and minor criteria, as published by the European Society of Cardiology.<cite>McKenna1994</cite><br />
<br />
ARVC is a progressive disease. The '''incidence''' is estimated to be 1:3.000-1:10.000. Manifestations are usually seen in teenagers. Although the diagnosis is more often made in athletes, sports are not thought to have a causative relationship with the disease. ARVD can occur in families; more than 9 different chromosomal defects have been described, most often with autosomal dominant inheritance. <br />
<br />
One unique form of ARVD, called Naxos disease (after the Greek island where it was first diagnosed), has an autosomal recessive pattern of inheritance. <br />
<br />
'''Diagnosis''' ARVC is a difficult diagnosis to make. Therefore, the European Society of Cardiology has created a list of diagnostic criteria for the diagnosis of ARVC<cite>#McKenna1994</cite> (see table).<br />
{| class="wikitable" width="400px"<br />
!Major diagnostic criteria for Arrhythmogenic Right Ventricular Cardiomyopathy<cite>McKenna1994</cite><br />
|-<br />
|<ul><li>Familial disease confirmed at necroscopy or surgery</li><br />
<li>Severe dilatation and reduction of right ventricular ejection fraction with no (or only mild) LV impairment</li><br />
<li>Localized right ventricular aneurysms (akinetic or diskinetic areas with diastolic bulging)</li><br />
<li>Severe segmental dilataion of the right ventricle</li><br />
<li>Fibrofatty replacement of myocardium on endomyocardial biopsy</li><br />
</ul><br />
|-<br />
!Diagnostic criteria that can be diagnosed on the ECG<br />
|-<br />
|<ul><br />
<li>(major) Epsilon wave or localized prolongation (>110ms) of the QRS complex in right precordial leads (V1-V3)</li><br />
<li>(minor) Inverted T waves in right precordial leads (V2 and V3) (people aged more than 12 yr; in absence of [[RBBB]]</li><br />
<li>(minor) [[Late potentials]] ([[SAECG|signal averaged ECG]])</li><br />
<li>(minor) Left bundle branch block type [[Ventricular Tachycardia|ventricular tachycardia]] (sustained and non-sustained) (ECG, [[Holter]], [[Exercise Testing|exercise testing]]</li><br />
<li>(minor) Frequent [[Ventricular Premature Beats|ventricular extrasystoles]] (more than 1000/24h) ([[Holter]])</li><br />
</ul><br />
|}<br />
In 2009 these criteria were updated<cite>cox</cite>, see the table below.<br />
<br />
'''Treatment''' focuses on avoiding complications.<cite>ACC2006</cite><br />
*Medication: <br />
**Anti-arrhythmics: Sotalol better than Amiodarone.<br />
**ACE-inhibitors to prevent cardiac remodelling<br />
*[[ICD]] implantation is recommended for the prevention of sudden cardiac death in patients with ARVC with documented sustained VT or VF who are receiving chronic optimal medical therapy.<br />
*[[ICD]] implantation can be considered for the prevention of sudden cardiac death in patients with ARVC with extensive disease, including those with left ventricular involvement, 1 or more affected family member with SCD (Sudden Cardiac Death), or undiagnosed syncope when [[Ventricular Tachycardia|ventricular tachycardia]] or [[Ventricular Fibrillation|ventricular Fibrillation]] has not been excluded as the cause of syncope, who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y.<br />
*Radiofrequency [[ablation]] can be useful as adjunctive therapy in management of patients with ARVC with recurrent [[Ventricular Tachycardia|ventricular tachycardia]], despite optimal antiarrhythmic drug therapy.<br />
<br />
<gallery><br />
Image:arvd_ecg1.png<br />
Image:arvd_ecg2.png<br />
Image:arvd_ecg3.png<br />
</gallery><br />
<br />
== Revised Task Force Criteria ARVD / ARVC==<br />
{| class="wikitable"<br />
|+ Comparison of Original and Revised Task Force Criteria<br />
! style="width:500px" | Original Task Force Criteria<br />
! style="width:500px" | Revised Task Force Criteria<br />
|-<br />
| colspan="2" | '''I. Global or regional dysfunction and structural alterations<sup>&lowast;</sup>'''<br />
|-<br />
| colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
| valign="top" style="padding-left:24px" |<br />
* Severe dilatation and reduction of RV ejection fraction with no (or only mild) LV impairment<br />
* Localized RV aneurysms (akinetic or dyskinetic areas with diastolic bulging)<br />
* Severe segmental dilatation of the RV<br />
| valign="top" |<br />
<strong>By 2D echo:</strong><br />
* Regional RV akinesia, dyskinesia, or aneurysm<br />
* and 1 of the following (end diastole):<br />
** PLAX RVOT &ge;32 mm (corrected for body size [PLAX/BSA] &ge;19 mm/m<sup>2</sup>)<br />
** PSAX RVOT &ge;36 mm (corrected for body size [PSAX/BSA] &ge;21 mm/m<sup>2</sup>)<br />
** <em>or</em> fractional area change &le;33%<br />
<strong>By MRI:</strong><br />
* Regional RV akinesia or dyskinesia or dyssynchronous RV contraction<br />
* <em>and</em> 1 of the following:<br />
** Ratio of RV end-diastolic volume to BSA &ge;110 mL/m<sup>2</sup> (male) or &ge;100 mL/m<sup>2</sup> (female)<br />
** <em>or</em> RV ejection fraction &le;40%<br />
<strong>By RV angiography:</strong><br />
* Regional RV akinesia, dyskinesia, or aneurysm<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
| valign="top" style="padding-left:24px" |<br />
* Mild global RV dilatation and/or ejection fraction reduction with normal LV<br />
* Mild segmental dilatation of the RV<br />
* Regional RV hypokinesia<br />
| valign="top" |<br />
<strong>By 2D echo:</strong><br />
* Regional RV akinesia or dyskinesia<br />
* <em>and</em> 1 of the following (end diastole):<br />
** PLAX RVOT &ge;29 to &lt;32 mm (corrected for body size [PLAX/BSA] &ge;16 to &lt;19 mm/m<sup>2</sup>)<br />
** PSAX RVOT &ge;32 to &lt;36 mm (corrected for body size [PSAX/BSA] &ge;18 to &lt;21 mm/m<sup>2</sup>)<br />
** <em>or</em> fractional area change &gt;33% to &le;40%<br />
<strong>By MRI:</strong><br />
* Regional RV akinesia or dyskinesia or dyssynchronous RV contraction<br />
* <em>and</em> 1 of the following:<br />
** Ratio of RV end-diastolic volume to BSA &ge;100 to &lt;110 mL/m<sup>2</sup> (male) or &ge;90 to &lt;100 mL/m<sup>2</sup> (female)<br />
** <em>or</em> RV ejection fraction &gt;40% to &le;45%<br />
|-<br />
| colspan="2" | '''II. Tissue characterization of wall'''<br />
|-<br />
| colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
| valign="top" style="padding-left:24px" |<br />
* Fibrofatty replacement of myocardium on endomyocardial biopsy<br />
|<br />
* Residual myocytes &lt;60% by morphometric analysis (or &lt;50% if estimated), with fibrous replacement of the RV free wall myocardium in &ge;1 sample, with or without fatty replacement of tissue on endomyocardial biopsy<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
|<br />
| valign="top" |<br />
* Residual myocytes 60% to 75% by morphometric analysis (or 50% to 65% if estimated), with fibrous replacement of the RV free wall myocardium in &ge;1 sample, with or without fatty replacement of tissue on endomyocardial biopsy<br />
|-<br />
| colspan="2" | '''III. Repolarization abnormalities'''<br />
|-<br />
|'''Bold text''' colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
| &nbsp;<br />
|<br />
* Inverted T waves in right precordial leads (V<sub>1</sub>, V<sub>2</sub>, and V<sub>3</sub>) or beyond in individuals &gt;14 years of age (in the absence of complete right bundle-branch block QRS &ge;120 ms)<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
| valign="top" style="padding-left:24px" |<br />
* Inverted T waves in right precordial leads (V<sub>2</sub> and V<sub>3</sub>) (people age &gt;12 years, in absence of right bundle-branch block)<br />
|<br />
* Inverted T waves in leads V<sub>1</sub> and V<sub>2</sub> in individuals &gt;14 years of age (in the absence of complete right bundle-branch block) or in V<sub>4</sub>, V<sub>5</sub>, or V<sub>6</sub><br />
* Inverted T waves in leads V<sub>1</sub>, V<sub>2</sub>, V<sub>3</sub>, and V<sub>4</sub> in individuals &gt;14 years of age in the presence of complete right bundle-branch block<br />
|-<br />
| colspan="2" | '''IV. Depolarization/conduction abnormalities'''<br />
|-<br />
| colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
| style="padding-left:24px" |<br />
* Epsilon waves or localized prolongation (&gt;110 ms) of the QRS complex in right precordial leads (V<sub>1</sub> to V<sub>3</sub>)<br />
|<br />
* Epsilon wave (reproducible low-amplitude signals between end of QRS complex to onset of the T wave) in the right precordial leads (V<sub>1</sub> to V<sub>3</sub>)<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
| style="padding-left:24px" valign="top" |<br />
* Late potentials (SAECG)<br />
|<br />
* Late potentials by SAECG in &ge;1 of 3 parameters in the absence of a QRS duration of &ge;110 ms on the standard ECG<br />
* Filtered QRS duration (fQRS) &ge;114 ms<br />
* Duration of terminal QRS &lt;40 <em>&micro;</em>V (low-amplitude signal duration) &ge;38 ms<br />
* Root-mean-square voltage of terminal 40 ms &le;20 <em>&micro;</em>V<br />
* Terminal activation duration of QRS &ge;55 ms measured from the nadir of the S wave to the end of the QRS, including R&acute;, in V<sub>1</sub>, V<sub>2</sub>, or V<sub>3</sub>, in the absence of complete right bundle-branch block<br />
|-<br />
| colspan="2" | '''V. Arrhythmias'''<br />
|-<br />
| colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
|<br />
|<br />
* Nonsustained or sustained ventricular tachycardia of left bundle-branch morphology with superior axis (negative or indeterminate QRS in leads II, III, and aVF and positive in lead aVL)<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
| style="padding-left:24px" valign="top" |<br />
* Left bundle-branch block–type ventricular tachycardia (sustained and nonsustained) (ECG, Holter, exercise)<br />
* Frequent ventricular extrasystoles (&gt;1000 per 24 hours) (Holter)<br />
|<br />
* Nonsustained or sustained ventricular tachycardia of RV outflow configuration, left bundle-branch block morphology with inferior axis (positive QRS in leads II, III, and aVF and negative in lead aVL) or of unknown axis<br />
* &gt;500 ventricular extrasystoles per 24 hours (Holter)<br />
|-<br />
| colspan="2" | '''VI. Family history'''<br />
|-<br />
| colspan="2" style="padding-left:12px" | '''Major'''<br />
|-<br />
| style="padding-left:24px" valign="top" |<br />
* Familial disease confirmed at necropsy or surgery<br />
|<br />
* ARVC/D confirmed in a first-degree relative who meets current Task Force criteria<br />
* ARVC/D confirmed pathologically at autopsy or surgery in a first-degree relative<br />
* Identification of a pathogenic mutation<sup>&dagger;</sup> categorized as associated or probably associated with ARVC/D in the patient under evaluation<br />
|-<br />
| colspan="2" style="padding-left:12px" | Minor<br />
|-<br />
| style="padding-left:24px" valign="top" |<br />
* Family history of premature sudden death (&lt;35 years of age) due to suspected ARVC/D<br />
* Familial history (clinical diagnosis based on present criteria)<br />
|<br />
* History of ARVC/D in a first-degree relative in whom it is not possible or practical to determine whether the family member meets current Task Force criteria<br />
* Premature sudden death (&lt;35 years of age) due to suspected ARVC/D in a first-degree relative<br />
* ARVC/D confirmed pathologically or by current Task Force Criteria in second-degree relative<br />
|-<br />
| colspan="2" |<br />
<ul><br />
<li>PLAX indicates parasternal long-axis view; RVOT, RV outflow tract; BSA, body surface area; PSAX, parasternal short-axis view; aVF, augmented voltage unipolar left foot lead; and aVL, augmented voltage unipolar left arm lead.</li><br />
<li>Diagnostic terminology for original criteria: This diagnosis is fulfilled by the presence of 2 major, or 1 major plus 2 minor criteria or 4 minor criteria from different groups. Diagnostic terminology for revised criteria: definite diagnosis: 2 major or 1 major and 2 minor criteria or 4 minor from different categories; borderline: 1 major and 1 minor or 3 minor criteria from different categories; possible: 1 major or 2 minor criteria from different categories.</li><br />
<li><sup>&lowast;</sup> Hypokinesis is not included in this or subsequent definitions of RV regional wall motion abnormalities for the proposed modified criteria.</li><br />
<li><sup>&dagger;</sup> A pathogenic mutation is a DNA alteration associated with ARVC/D that alters or is expected to alter the encoded protein, is unobserved or rare in a large non–ARVC/D control population, and either alters or is predicted to alter the structure or function of the protein or has demonstrated linkage to the disease phenotype in a conclusive pedigree.</li><br />
</ul><br />
|}<br />
<br />
==References==<br />
<biblio><br />
#McKenna1994 pmid=8142187<br />
#Corrado pmid=10768917<br />
#ACC2006 pmid=16949478<br />
#Corr pmid=19366719<br />
#cox pmid=20215590<br />
</biblio></div>77.251.13.40