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The Brugada Syndrome

So, I have been getting a few mails from the doctors and some patients to tell them about this genetically inherited condition, that may kill the bearer during sleep.

Now, be informed that the following information is best utilised by the treating or researching doctors and may or may not be very useful to the patients, unless of course, they want to just know what they are suffering from. Having said that, it is best not to take matters in your hand (the patients) and instead rely on a specialist doctor.

So what is the Brugada syndrome? A syndrome that has caught the fancy of the doctors and the patients- the world over- for killing the patient suddenly during sleep i.e. the patient goes to sleep and does not wake up.

I’m here to give my salient points regarding the syndrome, please be informed that I choose not to divulge the whole literature on it, because that would only make the topic exhaustive and boring, of a very interesting subject, anybody who would want to know a little more about the syndrome can mail me on my email that shall be provided at the end of the article. These are just the salient points on the topic.

So here goes:

Brugada syndrome is named after the Spanish cardiologists Pedro and Josep Brugada who described the condition in 1992, although the association between the characteristic ECG pattern and sudden cardiac death had been reported in 1989.

It is an inherited autosomal dominant condition.

It is mostly caused due to a loss of function SCN5A mutation, but it can also be inherited due to a missense mutation or due to a loss of function of the LTCC alpha and beta subunit encoded CACN 1C gene.

It is most commonly seen in the South-East Asian males, even though it can occur in all races and in the other gender too, but it certainly has a predilection towards males and south-east asians.

Brugada syndrome causes – Ventricular tachycardia, syncope or sudden cardiac death, while the patient sleeps.

So, the trigger is usually sleep, while the fear is of ventricular tachycardia, syncope or sudden cardiac death.

 

What are the ECG changes that can give a hint towards the condition?

  1. A pseudo-RBBB (Right bundle branch block) like pattern
  2. ST segment elevation in V1-V4 with charactertic ‘coved or saddle back’ appearance, leading to…
  3. Polymorphic ventricular tachycardia.

 

There are different types of Brugada syndrome and they can be broadly divided into-

BRS type 1 BRS type 2 BRS type 3
J wave amplitude >2mm >2mm >2mm
T wave negative biphasic positive
ST-T configuration coved saddle back saddle back

brugada syndrome

So what is the management salient points?

We can diagnose Brugada syndrome with the help of a provocative test  by using Procainamide.

Management- Ablation/ Quinidine.

If there is a presence of a VT storm- low dose isoproterenol has a role.

The treatment of choice is- ICD insertion.

 

brugada

So, I hope this helped you a bit with the brugada syndrome phenotype, of course, these are just a few salient points, feel free to ask me a question or add to the topic.

email me at- dr.rajatrawat.public@gmail.com

Have a great day !

Can exercise trigger a heart attack or sudden cardiac arrest/death?

athletic man with fit muscles doing push ups on kettlebells
Photo by Andrea Piacquadio on Pexels.com

It has long been understood that exercise is good for the body, and it really is, there are no doubts about it. Why then, the sensational title? The simple answer to it is, well, yes, exercise can trigger a heart attack or sudden cardiac arrest or death.

Let me explain it to you, and these statements have been picked up from one of the most sought after study in cardiology, the Framingham Study. Researchers, have long believed that sedentary lifestyle has been associated with a higher risk of mortality, from heart ailments. Now there are some researchers that have challenged this statement. They do not disagree to the statement, and everyone encourages you to exercise, and get yourself in shape. What is the issue then?

The issue is that in a retrospective study analyzing patients who had sudden cardiac arrest, the researchers found that, there were higher chances of sudden cardiac arrest or death, in patients undergoing heavy training/exercises; and in contrast, patients who relatively had less exercises had lower risk of sudden cardiac arrest or death. Now, this is sensational ! This can be found in the latest edition of Braunwald’s textbook of Cardiology in the Chapter: Sudden Cardiac Arrest.

When we analyse these statements, we can see, that they are relative, and are talking about acute stresses, in the form of heavy exercise, and the risk of mortality is lower, in case of sudden cardiac arrest/death, when people undergo less intensive workouts, hence giving less stress to the heart. So far so good. This means, that exercise, within limits, is beneficial, but as with anything, extremes of anything can be harmful. This is no way means, that people who are trained athletes, and who undergo rigorous exercise regimes, should stop what they are doing. Why? Let us analyse the next set of sentences.

The next set of sentence, in this research, point to the root of all cause, in such cases, and they have made it absolutely clear, in the context of myocardial infarction (heart attack). What is the statement?

“Higher risk of mortality and MI, has been amongst patients undergoing acute, high levels of exercise, especially patients who had a sedentary lifestyle, to begin with”.

Let us analyze this statement, in context of our present scenario. We know that the country, is undergoing serial unlock in view of the Covid-19 pandemic. A lot of people were not able to exercise as much as they used to, or have continued living their sedentary lifestyle and taken the lockdown as an excuse to continue getting low levels of exercise, and with the unlock happening, many of these people are waking up to changing their lifestyles and embracing working out.

This is good. But what we have to remember, is not to exert ourselves on day one, and take it slow. Start at your own normal pace, take a walk, stop when you feel the need to, and increase your capacity over the next few days and weeks. Remember, taking it slow, perseverance and gradual improvements, is what made the tortoise win the race.

Walk, run, Do Yoga, cycle, jog, play football, whatever, just take it slow. Let your body adapt.

Exercise is the best gift you can give to your body. Just listen to your body, when it says so. Have a nice day.

Less is more: The concept of minimalism

I recently watched an intriguing documentary on the popular streaming platform- netflix: Minimalism. It was about two guys, spreading the message of less is more, and to be honest, they had the idea sold. It hit the nail on the head.

Think of it like this, how many times, have you noticed the compulsive ads on television, targeting your vulnerabilities, and your desires, and then seeing them again on your social media feeds- subconsciously urging you to buy them? Till you don’t have no more power over your impulses and give in and buy a product you don’t need, just that, they made you feel that it was something you needed.

The concept of minimalism, is just that, not to acquire things that you don’t need. It is easier said than done though- it requires discipline, and self-control; but these might be the only things that you need, otherwise, minimalism is a hobby or a lifestyle, if you may, that saves money for a change, and that alone, can be a huge driving force for it to gain followers everyday.

How many times, has it happened, that you have a wardrobe full of clothes, and still find it difficult to actually wear something you like? Well, minimalism answers that. Take a half-day, arrange your clothes, give away/sell the clothes that you don’t like or are unlikely to wear. Now you have only the clothes that you like, and will find it easier to decide what to wear. Most people will end up with just 10-12 pair of clothing, and re-wear them again and again, and that’s okay. Don’t give in to the shame that these companies want to make you feel, about not owning enough stuff. You should be recognized from the work that you do, and the good person that you are, and not from some misplaced sense of achievement that comes from having hundreds of clothes, that these companies want you to believe in.

Want to buy a new car? How about trying to evaluate why you really want a new one? What happened to the existing one? Can it function better by correcting it’s flaws- like giving a new engine oil replacement, or maybe changing the oil filter. What? The air-conditioning is not that great? How about refilling the coolant? Tyres burning out? Get new tyres. Basically, only buy new stuff, when it is absolutely necessary. Not only is it, economical, it is ecological as well. You are resisting consumerism, and you, are a living revolution with this lifestyle.

But, with this lifestyle, comes a conscience, that says,” what maybe unnecessary to you, may actually be someone else’s necessity”. So throw away your unnecessary things, but keep this in mind, do you know someone, or is there someone, who might benefit from stuff that you are throwing away, so maybe, don’t throw it away, give it away.

Minimalism, doesn’t mean that you can’t have the collection of watches or books that you always wanted. Minimalism, says, that you can do anything, or acquire anything, that enhances your life, adds value to it. So, if your collection of books, or watches, adds value to your relationship, like when you lend books, and make you develop better bonds, or you like, maybe, aesthetics of the watches that make your day, or maybe you like the smell that comes with flipping the pages of those books- sure, go ahead, get that collection you always wanted. Just make sure, it shall add value to your life, in the coming days and years. Most people, just end up buying stuff, that gives them happiness for a day or two, or maybe a week, and become indifferent to it after sometime. Ask yourself before buying anything, will this matter in the years to come? If your answer is no, I think it is safe to out those green papers back in your pockets.

 

Like the minimalism lifestyle?

white wooden table with chairs in a room
Photo by cottonbro on Pexels.com

Interested? drop a mail at dr.rajatrawat.public@gmail.com and let me know.

Covid 19 and it’s cardiovascular implications

The world has went into a spiral, with the unprecedented emergence of the novel corona virus. It has put many developed countries to shame, and made the world realize, that more than equipment of mass destruction, we need instruments of healing. The need for doctors, healthcare workers, volunteers has never been higher, throughout the world.

Now there a lot of rumors that surround this virus, that it was man-made, so on and so forth. I am here to discuss facts- hard facts.

Corona Virus, the primary illness is that of a respiratory one, but there are instances and case series, where the heart has been involved. In fact, Corona virus disease can be seen as a disease involving multi-systems within the body, in it’s most severe form.

I’m here to talk about the cardiovascular implication of the novel corona virus. The corona virus can involve the heart by a variety of mechanisms-

  1. The respiratory distress that the disease causes, can lead to increased metabolic demand of the body, including the heart, that may lead to a substrate demand-supply mismatch, leading to myocardial infarction, or heart attack in simpler terms. Patients with a pre-existing heart ailment, like the presence of a pre-existing coronary artery disease, are particularly more vulnerable, because this pre-existing ailment, causes a decreased ability of the heart to increase it’s own blood supply, during stress, of any cause, this again leads to a demand and supply mismatch of the substrates (that travel via the blood) and lead to heart attack (Myocardial infarction; MI)
  2. Myocarditis– The virus can directly attack the myocytes (tissues of the heart) and cause inflammation of the heart, this can lead to various rhythm disturbances, that can precipitate sudden cardiac death.
  3. Arrhythmias- corona virus, can lead to myocarditis, as we already discussed in brief, this can lead to various rhythm disorders- including fast rhythms (tachy-arrhythmias) and slow abnormal rhythms (bradyarrhythmias)- these can lead to sudden cardiac death.
  4. Electrolyte disturbances- any illness can lead to electrolyte disturbances and that can lead to arrhythmias again, and also lead to sudden cardiac death.
  5. Heart failure- patients can have heart failure, de novo (new onset) or may have precipitation or decompensation of heart failure in patients with pre-existing heart ailment.
  6. Long term sequelae- the long term sequelae of the novel corona virus on the heart is still to be studied and investigated and we need to keep recovered patients in follow-up to best judge the situation.

There have been several case reports and series, where raised cardiac enzymes, particularly trop-i, has been associated with a worse outcome, when compared with patients with normal cardiac enzyme levels and/or mildly elevated levels. This highlights the importance and gravity of the situation if one develops cardiac manifestation with a covid-19 infection.

The effect of proposed drugs is not to be taken lightly as well- drugs like hydroxychloroquine can lead to QT prolongation (also, azithromycin and many other anti-virals) that can lead to sudden cardiac death. This is why I recommend a baseline ECG to look for a pre-existing QT prolongation to assess the risk of such medication and then follow it up with daily ECGs/EKGs.

These are tough times, where the best we can do, till a definitive cure comes, is to stay at home and try and do something productive. Work from home, if you can. Wash your hands frequently. Don’t touch your face. Maintain social distancing of about 2 meters at all times. Only go out, if it is absolutely necessary. Remember, prevention shall always be better than cure.

 

If you have any serious inquiries, and want me to clear any doubts, or just want to connect or collaborate- email me.

The Buddhist prayer of peace

Through the virtue of this effort to enter into the ways leading to enlightenment, may all living beings come to engage in these conducts:

May all beings everywhere plagued with sufferings of body and mind, obtain an ocean of happiness and joy by virtue of my merits.

For as long as they remain in cyclic existence, may their happiness never decline, and may all of them uninterruptedly receive waves of joy from all Bodhisattvas.

May those feeble with cold find warmth, and may those oppressed with heat be cooled by the boundless waters that pour forth from the great clouds of the Bodhisattvas.

May all animals be free from fear. May the blind see forms, may the deaf hear sounds. May pregnant women give birth without any pain.

May the naked find clothing, and the hungry find food. May the forlorn find new hope, constant happiness and prosperity.

May all who are sick and ill quickly be freed from their illnesses, and may every disease in the world never occur again.

May the frightened cease to be afraid, and may those bound be free. May the powerless find power, and may people think of befriending one another.

May all travelers find happiness everywhere they go, and without any effort may they accomplish whatever they set out to do.

May the troubled wanderers who have lost their way meet with fellow travelers. May they live without fear.

May those who find themselves in trackless, fearful wildernesses, the children, the aged, the unprotected, be guarded by beneficent celestials.

May pregnant women give birth without any pain, just like the treasury of space.

May all embodied creatures uninterruptedly hear the sound of Dharma issuing from birds and trees, beams of light, and even space itself.

May celestials bring timely rains so that harvests may be bountiful. May leaders act in accordance with Dharma and the people of the world always prosper.

May no living creature ever suffer, commit evil or fall ill. May no one be afraid or belittled, or their minds ever be depressed.

May beings not experience the misery of lower realms, and may they never know any hardships. May they swiftly attain Buddhahood.

For as long as space endures, and for as long as living beings remain, until then may I too abide to dispel the misery of the world.

May all the pains of living creatures ripen solely upon myself, and may all beings experience unending happiness.

(From The Dedication Chapter of Engaging the Ways of the Bodhisattva, by eighth century Buddhist saint and scholar Shantideva.)