Electrocardiography Series

Singapore Med J 2011; 52(10) : 195

CME Article

Managing ventricular ectopics: are ventricular ectopic beats just an annoyance?

Cardiac Department, National University Heart Centre, 1E Kent Ridge Road, NUHS o!er "loc#, $evel %, Singapore 11%&&' Lee LC, MRCP Associate Consultant (ong $oo $in School o) Medicine Seow SC, MRCP, FACC Consultant Teo S , MRCP Consultant Po! "", FRCP, FACC, FAS# Senio$ Consultant an% Associate P$o&esso$

%ig& ' ECG shows ventricular bigeminy.

Ra))les Heart Centre, Ra))les Hospital, *'* North "ridge Road, +1&,--, Singapore 1''..8*a$ AR, MRCP, FACC Consultant Correspondence to/ 9$ A/%ul Ra:a4;$ 8*a$ Tel: (<5) <=11 22<0 Fa3: (<5) <=11 11>' #*ail: $a:a41=? )a!oo0co*0s,

CL()(CAL "RESE) A (O) A '0()ea$(ol% wo*an was $e&e$$e% &o$ an e+aluation o& an inci%ental &in%in, o& &$e-uent +ent$icula$ ecto.ic /eats &oun% in t!e $estin, 12(lea% elect$oca$%io,$a* (#C )0 S!e !a% occasional .al.itations /ut no s)nco.e o$ a c!an,e in !e$ e&&o$t tole$ance0 T!e .atient !a% a .ast !isto$) o& 1a

s*all !ole in t!e !ea$t20 T!e$e was no si,ni&icant &a*il) !isto$) o& !ea$t %isease o$ su%%en ca$%iac %eat!0 P!)sical e3a*ination was un$e*a$4a/le a.a$t &$o* a s)stolic *u$*u$ t!at was au%i/le o+e$ t!e le&t ste$nal e%,e0 5ase% on t!e 12(lea% #C (Fi, 1), s!e was t$eate% wit! *eto.$olol 25 *, twice %ail)0 6!at %oes Fi,0 1 s!ow7

Singapore Med J 2011; 52(10) : 19<

EC! () ER"RE A (O) Fi,0 1 s!ows +ent$icula$ /i,e*in)0 T!e .$e*atu$e +ent$icula$ co*.le3 (P@C) !as a le&t /un%le /$anc! /loc4 *o$.!olo,) an% in&e$io$ a3is, su,,estin, t!at it o$i,inates &$o* t!e $i,!t +ent$icula$ out&low t$act (R@8T)0 CL()(CAL CO*RSE T!e .atient un%e$went 2'(!ou$ #C *onito$in,, w!ic! s!owe% 2>,=51 isolate% P@Cs wit! &$e-uent $uns o& +ent$icula$ /i,e*in), +ent$icula$ cou.let an% non(sustaine% +ent$icula$ tac!)ca$%ia (AS@T), wit! t!e lon,est $un at 25 consecuti+e /eats at a +ent$icula$ $ate o& 1BB /eats .e$ *inute (/.*)0 T$anst!o$acic ec!oca$%io,$a* was no$*al e3ce.t &o$ a s*all $est$icti+e .e$i*e*/$anous +ent$icula$ se.tal %e&ect0 T!e co$ona$) an,io,$a* was also no$*al0 T!e /eta /loc4e$ t!e$a.) %i% not si,ni&icantl) $e%uce t!e P@C loa% an% se+e$it)0 T!e !i,! P@C loa% (C 20,000D2' !ou$s) an% t!e .$esence o& closel) cou.le% P@Cs inc$ease% ou$ conce$n, as t!e .ossi/ilit) o& a *ali,nant +a$iant o& R@8T +ent$icula$ a$$!)t!*ia is associate% wit! a !i,! $is4 o& su%%en ca$%iac %eat! (SC9)0 A success&ul R@8T $a%io&$e-uenc) cat!ete$ a/lation was .e$&o$*e%, wit! co*.lete a/olis!*ent o& t!e P@Cs0 +(SC*SS(O) Si$ Ea*es Mac4en:ie was t!e &i$st to %esc$i/e e3t$as)stoles in 1>90 w!en !e notice% t!at c!a*/e$s o& t!e !ea$t coul% /eat outsi%e o& t!ei$ co$$ect o$%e$0(1) To%a), +ent$icula$ e3t$as)stoles a$e o$ also calle% .$e*atu$e +ent$icula$ co*.le3es +ent$icula$ cont$actions,

conte3t o& un%e$l)in, .oo$ *)oca$%ial &unction, connote a .oo$e$ .$o,nosis0 0revalence A .o.ulation stu%) s!owe% t!at P@Cs we$e $eco$%e% on stan%a$% 12(lea% #C s in 00>H o& su/;ects in a !ealt!) *ilita$) .o.ulation, wit! a .$e+alence o& 005H in t!ose un%e$ t!e a,e o& 20 )ea$s an% 202H in t!ose o+e$ 50 )ea$s o& a,e0(2) In t!e F$a*in,!a* Fea$t Stu%), t!e .$e+alence o& .atients !a+in, J one P@C .e$ !ou$ in a one(!ou$ a*/ulato$) #C *onito$in, was ==H in *en an% =2H in wo*en wit!out co$ona$) a$te$) %isease (CA9)0 A*on, .atients wit! esta/lis!e% CA9, t!e .$e+alence was 5>H in *en an% '9H in wo*en0(=) T!e wi%e +a$ia/ilit) o& %ata $e.o$te% is li4el) $elate% to t!e %i&&e$ent %u$ations o& *onito$in, &o$ P@C .$e+alence, w!ic! co$$elates wit! inc$easin, a,e, t!e .$esence sinus $ates, o& !ea$t %isease, !).e$tension, &aste$ A&$ican(A*e$ican

et!nicit), *ale ,en%e$, lowe$ e%ucational attain*ent an% lowe$ se$u* *a,nesiu* o$ .otassiu* le+els0(') 0athophysiology T!e .$o/a/le *ec!anis*s &o$ P@Cs inclu%e en!ance% auto*aticit), $e(ent$) an% t$i,,e$e% acti+it)0 In en!ance% auto*aticit), an ecto.ic +ent$icula$ &ocus &i$es s.ontaneousl)0 T!is *a) occu$ in $es.onse to a !ei,!tene% a%$ene$,ic state, *)oca$%ial isc!ae*ia o$ elect$ol)te i*/alance0 #a$l) a&te$(%e.ola$isations t$i,,e$e% /) a .$ece%in, i*.ulse can lea% to .$e*atu$e +ent$icula$ ecto.ics i& t!e cell *e*/$ane acti+ation t!$es!ol% is e3cee%e%0 T!is *ec!anis* is o&ten $es.onsi/le &o$ /$a%)ca$%ia(associate% P@Cs, /ut is also i*.licate% in P@Cs in%uce% /) isc!ae*ia, elect$ol)te a/no$*alities an% %i,o3in to3icit)0 Re(ent$ant P@Cs t).icall) o$i,inate in a$eas o& %i&&e$ential con%uction %ue to sca$$in, o$ isc!ae*ia0 01C in str2ct2rally normal heart 6!at is t!e si,ni&icance o& P@Cs in a st$uctu$all) no$*al !ea$t7 "enne%) et al an% #n,st$o* et al &oun% no co$$elation /etween &$e-uentDco*.le3 P@Cs an% *o$talit) o$ ca$%iac e+ents in *en wit!out CA90(5,<) Fowe+e$, t!e$e we$e con&lictin, &in%in,s in ot!e$ stu%ies0
(B,>)

.$e*atu$e /eats o$ +ent$icula$ ecto.ics0

T!e) a$e cause% /) t!e s.ontaneous &i$in, o& ecto.ic &oci in t!e +ent$icle(s)0 Fence, on su$&ace #C s, t!e) a$e $e&lecte% /) GRS co*.le3es t!at a$e wi%e (C 120 *s) an% not .$ece%e% /) P wa+es0 Most .atients wit! P@Cs a$e as)*.to*atic, alt!ou,! a s*all *ino$it) *a) e3.e$ience .al.itations o$ %i::iness0 P@Cs a$e one o& t!e *ost co**on a$$!)t!*ias an% can occu$ in .atients wit! o$ wit!out un%e$l)in, !ea$t %isease0 T!e .$o,nostic i*.o$tance o& P@Cs is +a$ia/le0 Fowe+e$, *ost su/;ects, e+en wit! &$e-uent P@Cs, !a+e e3cellent outco*e i& t!e$e is no un%e$l)in, st$uctu$al !ea$t %isease o$ con,enital c!annelo.at!ies suc! as t!e 5$u,a%a s)n%$o*e o$ .$olon,e% GT s)n%$o*e0 8n t!e ot!e$ !an%, P@Cs !a+e /een associate% wit! an inc$ease% $is4 o& su%%en %eat! in so*e .atients0 T!e .$esence an% se+e$it) un%e$l)in, st$uctu$al !ea$t %isease o& t!e is t!e *ost

In t!e F$a*in,!a* Fea$t Stu%), *en wit!

&$e-uent P@Cs !a% a two(&ol% inc$ease in t!e &i+e()ea$ *o$talit) $is4 an% ca$%iac e+ent $ate (a&te$ co$$ection o& ot!e$ ca$%io+ascula$ $is4 &acto$s) co*.a$e% to t!ose wit!out0(B) Also, in t!e Multi.le Ris4 Facto$ Inte$+ention T$ial (MRFIT), P@Cs we$e associate% wit! a si,ni&icantl) !i,!e$ $is4 o& SC9 wit! an a%;uste% $is4 $atio (RR) o& =00, /ut we$e not associate% wit! an) si,ni&icant inc$ease in t!e $is4 o&

i*.o$tant %ete$*inant o& a .oo$e$ .$o,nosis, &ollowe% /) t!e &$e-uenc) an% c!a$acte$istics o& t!e P@Cs0 F$e-uent, *ulti*o$.!ic P@Cs, .a$ticula$l) in t!e

%eat!s

&$o*

CA90

F$e-uent

o$

co*.le3
(>)

P@Cs

su/se-uent *o$talit), an% we$e st$on,l) $elate% to .oo$ le&t +ent$icula$ &unction (i0e0 L@#F)0(1') Fowe+e$, a&te$ a%;ust*ent was *a%e &o$ L@#F, no si,ni&icant association $e*aine% /etween +ent$icula$ a$$!)t!*ias an% *o$talit)0 Ca$%io*)o.at!) It !as /een esti*ate% t!at B0HK95H o& .atients wit! ca$%io*)o.at!) an% con,esti+e !ea$t &ailu$e !a+e &$e-uent P@Cs, an% '0HK>0H *ani&est $uns o& AS@T, w!ic! is associate% wit! !i,!e$ *o$talit)0(15) E3ercise,ind2ced 01Cs Au*e$ous stu%ies !a+e $e.o$te% t!e association o& P@Cs %u$in, e3e$cise wit! all(cause *o$talit) i$$es.ecti+e o& t!e .$esence o& ca$%io.ul*ona$) %isease o$ e3e$cise( in%uce% isc!ae*ia0(1<,1B) Its .$e%icti+e +alue was also s!own to /e in%e.en%ent o& $estin, P@Cs0 (1<) Mo$e i*.o$tantl), P@Cs .$e%icte% ca$%io+ascula$ *o$talit) to t!e sa*e %e,$ee as a .ositi+e isc!ae*ic $es.onse, an% its .$e%icti+e +alue was in%e.en%ent o& t!e .$esence o$ a/sence o& isc!ae*ic c!an,es on t!e e3e$cise #C 0(1B) Anot!e$ stu%) o& 29,2'' .atients o+e$ &i+e )ea$s %e*onst$ate% t!at &$e-uent P@Cs %u$in, t!e $eco+e$) .!ase o& t!e e3e$cise st$ess test was a st$on,e$ .$e%icto$ o& an inc$ease% $is4 o& *o$talit)0(1>) Fowe+e$, a &ew ot!e$ stu%ies !a+e &aile% to esta/lis! t!is $elations!i.0 T!e association /etween e3e$cise(in%uce% P@Cs an% ca$%io+ascula$ *o$talit) is .lausi/le, /ut t!e e3tent o& its clinical i*.lication in as)*.to*atic in%i+i%uals wit! st$uctu$all) no$*al !ea$ts is as )et unce$tain0 Most o& t!e stu%ies to %ate we$e *e$el) %esi,ne% to %ete$*ine t!e .$e%icti+e +alue o& P@Cs an% %i% not consi%e$ its *ec!anis* %u$in, e3e$cise0 01C in the elderly T!e .$e+alence o& P@Cs inc$eases wit! a,e, an% t!ei$ occu$$ence !as /een associate% wit! an inc$ease in total an% ca$%io+ascula$ *o$talit)0 An e.i%e*iolo,ical stu%) %e*onst$ate% t!at P@Cs in su/;ects wit! st$uctu$all) no$*al !ea$ts ca$$ie% no a%+e$se .$o,nostic si,ni&icance un%e$ t!e a,e o& =0 )ea$s, /ut in t!ose ol%e$ t!an =0 )ea$s, t!e .$esence o& P@Cs /e,an to in&luence t!e $is4 o& CA90(19) Anot!e$ stu%) in t!e Aet!e$lan%s also su,,este% t!at t!e .$esence o& P@Cs an% a &ast /aseline !ea$t $ate (w!ic! a$e *a$4e$s o& s)*.at!etic %o*inance) we$e .$e%icti+e o& *o$talit) in ol% a,e0(20) T!is, !owe+e$, $e*ains a contentious issue, wit! stu%ies on !ealt!) ,e$iat$ic in%i+i%uals counte$in, t!is &in%in,0(21) F$o* t!ese con&lictin, $esults, it is $easona/le to conclu%e t!at t!e .$o,nostic si,ni&icance o& P@Cs %e.en%s .$i*a$il) on t!e un%e$l)in, su/st$ate o& st$uctu$al !ea$t %isease, t!e .$e+alence o& w!ic! ten%s to inc$ease wit! a%+ancin, a,e,

(*ulti&o$*, .ai$s, $uns, R(on(T) le% to a si,ni&icantl) !i,!e$ $is4 o& SC9 (a%;uste% RR '02)0 5ot! t!e F$a*in,!a* an% MRFIT stu%ies &ollowe% u. t!ei$ su/;ects &o$ u. to si3 an% se+en )ea$s, $es.ecti+el)0 9es.ite t!e con&lictin, %ata, in ,ene$al, P@Cs in !ealt!) in%i+i%uals wit!out an) st$uctu$al !ea$t %isease %o not usuall) .ose an) $is4 o& SC90 01C in heart disease T!e inci%ence, &$e-uenc) an% co*.le3it) o& +ent$icula$ a$$!)t!*ias a$e ,$eate$ in t!e .$esence o& 4nown o$ sus.ecte% !ea$t %isease0 Intuiti+el), t!e *ana,e*ent o& P@Cs cent$es a$oun% t!e e3clusion o& st$uctu$al an% co$ona$) !ea$t %iseases0 Post *)oca$%ial in&a$ction T!e inci%ence o& s.ontaneous +ent$icula$ a$$!)t!*ias in t!e .ost(in&a$ction .e$io% can /e as !i,! as >5H &o$ P@Cs an% 11H &o$ AS@T0(9) In t!e ISSI 2 stu%), t!e .$esence o& *o$e t!an ten P@Cs .e$ !ou$ .$io$ to %isc!a$,e was associate% wit! <H *o$talit)0 F$e-uent P@Cs itsel& was also an in%e.en%ent $is4 &acto$ &o$ total ca$%iac %eat! an% SC9 in t!e &i$st si3 *ont!s &ollowin, t!e in&a$ction0 (10) In a%%ition, .ol)*o$.!ic P@Cs connote a .oo$e$ .$o,nosis t!an uni&o$* *o$.!olo,ic P@Cs0 T!e .$esence o& co*.le3 P@Cs (%e&ine% as R(on(T, $uns o& two o$ *o$e, *ulti&o$* o$ /i,e*inal co*.le3es) con&e$$e% a 25H $is4 o& ca$%iac %eat!, co*.a$e% wit! <H in *en w!o we$e &$ee o& P@Cs /) &i+e )ea$s0(11) P@Cs an% le&t +ent$icula$ in%e.en%entl) %)s&unction
(12)

Mo$e we$e Le&t

i*.o$tantl), a la$,e *ulticent$e stu%) conclu%e% t!at $elate% to *o$talit) $is40

+ent$icula$ e;ection &$action (L@#F) /elow =0H was &oun% to /e a /ette$ .$e%icto$ o& ea$l) *o$talit) (less t!an si3 *ont!s) an% t!e .$esence o& +ent$icula$ a$$!)t!*ias was a /ette$ .$e%icto$ o& late *o$talit) (a&te$ si3 *ont!s)0(12) T!e $ate o& P@Cs .e$ !ou$ *easu$e% one )ea$ a&te$ t!e in%e3 in&a$ction !as also /een s!own to /e !i,!l) .$e%icti+e o& su/se-uent %eat!0(1=) T!e$e&o$e, it is $easona/le to conclu%e t!at t!e .$esence o& P@Cs a&te$ acute *)oca$%ial in&a$ction is associate% wit! an inc$ease% total *o$talit) in so*e .atients, .a$ticula$l) t!ose wit! i*.ai$e% le&t +ent$icula$ &unction0 Its si,ni&icance is en!ance% wit! t!e co*.le3it) an% $ate o& its occu$$ence0 Sta/le co$ona$) a$te$) %isease (CA9) Cali&& et al e+aluate% t!e si,ni&icance o& +ent$icula$ a$$!)t!*ias a$$!)t!*ias usin, we$e 2'(!ou$ a*/ulato$) *onito$in, wit! in .atients wit! CA90 T!e) &oun% t!at +ent$icula$ in%e.en%entl) associate%

t!us lea%in, to t!e o/se$+ation o& a co$$elation /etween a,e an% .$e+alence o& P@Cs0 01C in special gro2ps P$e,nanc) P@Cs *a) inc$ease in &$e-uenc) %u$in, .$e,nanc) in ot!e$wise !ealt!) wo*en0 Fo$tunatel), *ost o& t!ese a$e /eni,n an% %o not $e-ui$e s.eci&ic t$eat*ent0 Most antia$$!)t!*ic %$u,s a$e sa&e e3ce.t &o$ a*io%a$one, w!ic! !as /een associate% wit! si,ni&icant &oetal a/no$*alities0 Ae+e$t!eless, $eassu$ance is t!e o.ti*al *ana,e*ent i& no $e+e$si/le cause is &oun%0 F).e$t$o.!ic o/st$ucti+e ca$%io*)o.at!) (FCM) To %ate, t!e$e is li*ite% %ata su,,estin, t!at &$e-uent P@Cs a$e, /) t!e*sel+es, in%icati+e o& an inc$ease% $is4 o& sustaine% +ent$icula$ a$$!)t!*ia0 It !as a low .ositi+e an% $elati+el) !i,! ne,ati+e .$e%icti+e +alue &o$ su%%en %eat! %es.ite its &$e-uent occu$$ence in t!is .o.ulation0 In a 2'(!ou$ Folte$ *onito$in, stu%), >>H o& .atients wit! FCM !a% P@Cs, inclu%in, 12H wit! C 500 P@Cs, '2H wit! cou.lets, =BH wit! S@T, an% =1H wit! AS@T0
(22)

o& +ent$icula$ %)s&unction o$ s)*.to*s, isolate% P@C !as *ini*al .$o,nostic si,ni&icance in t!ese in%i+i%uals0 Antia$$!)t!*ic t!e$a.) is not in%icate% &o$ as)*.to*atic .atients wit! isolate% P@Cs0 At!letes It is well 4nown t!at co*.etiti+e at!letes a$e at a !i,!e$ $is4 o& SC9 co*.a$e% to t!e ,ene$al a,e(*atc!e% .o.ulation0 T!e *a;o$ causes o& SC9 in at!letes a$e FCM (=<H),
(2=)

co$ona$) T!e

a$te$)

ano*alies %)s.lasia

(19H), an%

a$$!)t!*o,enic $i,!t +ent$icula$ *)oca$%itis0

.$esence o& P@Cs in at!letes

wa$$ants ca$e&ul e+aluation, as t!e) *a) .oint to un%e$l)in, st$uctu$al ca$%iac ano*alies0 T!e 2005 =<t! 5et!es%a Con&e$ence $eco**en%s t!at at!letes wit!out st$uctu$al !ea$t %isease w!o !a+e P@Cs at $est as well as %u$in, e3e$cise an% e3e$cise testin, (co*.a$a/le to t!e s.o$t in w!ic! t!e) co*.ete) can .a$tici.ate in all co*.etiti+e s.o$ts0 Fowe+e$, i& t!e at!letes e3.e$ience s)*.to*atic P@Cs %u$in, e3e$cise, t!e) can onl) .a$tici.ate in s.o$ts suc! as ,ol&, /illia$%s, /owlin,, c$ic4et, cu$lin, an% $i&le$)0 At!letes wit! st$uctu$al !ea$t %isease, w!o a$e %ee*e% to /e at !i,!($is4 an% w!o !a+e P@Cs, can onl) .a$tici.ate co*.etiti+el) in low(intensit) s.o$ts0(2<) Eval2ation o) 01Cs A %etaile% !isto$), inclu%in, %$u, an% &a*il) !isto$), !el.s to i%enti&) !i,!($is4 .atients $e-ui$in, &u$t!e$ I%io.at!ic +ent$icula$ out&low t$act +ent$icula$ tac!)ca$%ia I%io.at!ic @T is a &ai$l) co**on t).e o& @T, wit! a st$uctu$all) no$*al !ea$t seen in )oun, to *i%%le a,e% in%i+i%uals0 T!e c!a$acte$istic #C .atte$n &o$ t!ese a$$!)t!*ias is a le&t /un%le(/$anc! /loc4 .atte$n wit! in&e$io$(a3is *o$.!olo,) i& it is o& an R@8T o$i,in0 Alt!ou,! t!e .$o,nosis is ,ene$all) ,oo%, t!e$e is a *ali,nant +a$iant c!a$acte$ise% /) +e$) &$e-uent P@Cs (%e&ine% as C 20,000 P@Cs .e$ %a)) an% P@Cs wit! a s!o$t cou.lin, inte$+al in a%%ition to a !isto$) o& s)nco.e0
(2')

T$eat*ent o& P@Cs is wa$$ante% onl) in s)*.to*atic .atients0 T!e 200< A*e$ican Fea$t AssociationDA*e$ican Colle,e o& Ca$%iolo,)D#u$o.ean Societ) o& Ca$%iolo,) (AFADACCD#SC) consensus state*ent on t!e *ana,e*ent o& FCM $eco**en%e% /eta(/loc4e$s o$ +e$a.a*il, i& in%icate%0(2=)

$is4 st$ati&ication0 T!e .$o,nosis an% *ana,e*ent a$e in%i+i%ualise% acco$%in, to s)*.to* /u$%en an% se+e$it) o& un%e$l)in, !ea$t %isease, in a%%ition to t!e clinical .$esentation0 T!e$e&o$e su%%en e.iso%es o& colla.se wit! loss o& consciousness *a) constitute a !i,! $is4 w!en co*.a$e% to a .$esentation o& .al.itations0 P!)sical e3a*ination is o&ten un$e+ealin, in suc! .atients w!o .$esent wit! P@Cs0 T!e *ain &ocus o& clinical e3a*ination is towa$% e+aluatin, un%e$l)in, st$uctu$al !ea$t %isease0 A stan%a$% 12(lea% $estin, #C wit! a $!)t!* st$i. allows t!e .!)sician to c!a$acte$ise an% localise t!e P@Cs0 I*.o$tantl), it allows &o$ i%enti&ication o& $elate% i*.o$tant elect$ical a/no$*alities suc! as lon, o$ s!o$t GT s)n%$o*e, 5$u,a%a s)n%$o*e, a$$!)t!*o,enic $i,!t +ent$icula$ %)s.lasia o$ elect$ol)tes %istu$/ances0 Also, it *a) su,,est un%e$l)in, st$uctu$al o$ isc!ae*ic !ea$t %isease, w!ic! e3.lains t!e .$esence o& t!e P@Cs0 In a%%ition, GRS %u$ation an% $e.ola$isation a/no$*alities a$e /ot! in%e.en%ent .$e%icto$s o& SC90 In so*e stu%ies, ST se,*ent %e.$ession o$ T(wa+e a/no$*alities a$e associate% wit! u. to &ou$ ti*es inc$ease% $is4 o& ca$%io+ascula$ %eat! an% SC90(2B) A .$olon,e% GTc inte$+al is also an in%e.en%ent .$e%icto$ o& SC9, wit!

#3clusion o& $i,!t +ent$icula$ %)s.lasia is i*.o$tant,

es.eciall) i& t!e$e a$e @Ts o& %i&&e$ent *o$.!olo,ies o$ a &a*il) !isto$) o& su%%en %eat!0 P@Cs a$isin, &$o* t!e le&t +ent$icula$ out&low t$act !a+e $i,!t /un%le /$anc! /loc4 *o$.!olo,) an% a..ea$ to !a+e a si*ila$ .$o,nosis as t!ose o$i,inatin, &$o* t!e R@8T0 Con,enital !ea$t %isease A *eta(anal)sis o& =9 stu%ies, inclu%in, ',<2B .atients wit! co$$ecte% con,enital !ea$t %isease, s!owe% t!at t!e co*/ination o& +ent$icula$ %)s&unction an% co*.le3 P@Cs co$$elates wit! late SC90(25) Fowe+e$, in t!e a/sence

GTc C ''0 *s si,ni&icantl) .$e%ictin, ca$%io+ascula$ %eat! wit! an a%;uste% $elati+e $is4 o& 2010(2>) A GTc L =00 *s, w!ic! is o&ten use% to %e&ine t!e s!o$t GT s)n%$o*e, is an in%e.en%ent .$e%icto$ o& SC90(29) 5loo% sa*.lin, &o$ elect$ol)tes is i*.o$tant, loo4in, in .a$ticula$ &o$ !).o4alae*ia an% !).o*a,nesae*ia0 Plas*a le+els o& .$o(a$$!)t!*ic *e%ications o$ t!e .$esence o& sus.ecte% illicit %$u,s *a) also /e c!ec4e%0 Con+entional Folte$ a*/ulato$) *onito$in, is use&ul i& t!e s)*.to*s a$e su,,esti+e an% 12(lea% #C is un$e+ealin,0 Suc! tec!ni-ues can /e +e$) !el.&ul not onl) in %ia,nosin, a sus.ecte% case /ut i*.o$tantl), also in esta/lis!in, P@C &$e-uenc) an% co*.le3it), w!ile $elatin, t!e s)*.to*s to t!e .$esence o& t!e a$$!)t!*ia0 6!ile a 2'( to '>(!ou$ continuous Folte$ $eco$%in, is a..$o.$iate w!ene+e$ t!e a$$!)t!*ia is 4nown o$ sus.ecte% to occu$ at least once a %a), con+entional e+ent *onito$s a$e *o$e a..$o.$iate &o$ s.o$a%ic e.iso%es /ecause o& t!ei$ e3ten%e% $eco$%in, ca.a/ilit)0 Recentl), an i*.lanta/le loo. $eco$%e$ (w!ic! allows $eco$%in, o& #C s &o$ u. to t!$ee )ea$s) !as /een s!own to /e e3t$e*el) use&ul in %ia,nosin, se$ious tac!)a$$!)t!*ias an% /$a%)a$$!)t!*ias in .atients wit! li&e(t!$eatenin, s)*.to*s suc! as s)nco.e0 T!e $ea%il) a+aila/le, .e$&o$*s $elati+el) an ine3.ensi+e $ole in ec!oca$%io,$a.!) i*.o$tant

an% se+e$it) o& t!e un%e$l)in, !ea$t %isease, t!e .$esence o$ a/sence o& s.ontaneous @T, conco*itant %$u, t!e$a.), t!e sti*ulation .$otocol an% t!e site o& sti*ulation0 T!e !i,!est in%uction $ates an% $e.$o%uci/ilit) a$e o/se$+e% in .atients a&te$ *)oca$%ial in&a$ction0(=1) T!e .$esence o& P@Cs, .a$ticula$l) &$e-uent co*.le3 P@Cs in .ost( *)oca$%ial in&a$ction .atients o$ t!ose at !i,!e$ $is4 o& su%%en %eat! wa$$ants &u$t!e$ e+aluation in o$%e$ to %ete$*ine &utu$e a$$!)t!*ic $is40 #P testin, is .$o/a/l) use&ul in t!e e+aluation o& .atients wit! $e*ote *)oca$%ial in&a$ction an% s)*.to*s su,,esti+e o& +ent$icula$ tac!)a$$!)t!*ia, suc! as .al.itations, .$es)nco.e an% s)nco.e0 (2=) 6!ile #P testin, is not

$e-ui$e% in $ecent t$ials suc! as MA9IT II an% Su%%en Ca$%iac 9eat! in Fea$t Failu$e (SC9(FeFT), in t!e ea$lie$ MA9IT t$ial, in%uci/ilit) o& @T in .atients wit! AS@T on Folte$ *onito$in, i%enti&ie% a .o.ulation at !i,! $is4 &o$ @TD +ent$icula$ &i/$illation0(=2) Fowe+e$, #P testin, *a) onl) .la) a *ino$ $ole in non(isc!ae*ic %ilate% ca$%io*)o.at!) %ue to its low in%uci/ilit) an% low $e.$o%uci/ilit) as well as t!e low .$e%icti+e +alue o& in%uce% @T0(2=) In +ent$icula$ out&low t$act +ent$icula$ tac!)a$$!)t!*ia, #P testin, &o$ t!e e+aluation o& out&low t$act @T is /asicall) si*ila$ to t!at &o$ ot!e$ @T entities w!ose ai* is to esta/lis! .$ecise %ia,nosis to ,ui%e cu$ati+e cat!ete$ a/lation0(==) #P testin, $e*ains unclea$ o$ cont$o+e$sial in a$$!)t!*o,enic $i,!t +ent$icula$ ca$%io*)o.at!) an% FCM0 #C tec!ni-ues suc! as si,nal(a+e$a,e% #C (SA#C ), T 6a+e Alte$nant (T6A) testin,, !ea$t $ate +a$ia/ilit), /a$o&le3 sensiti+it) an% !ea$t $ate tu$/ulence *a) /e use&ul &o$ i*.$o+in, t!e %ia,nosis an% $is4 st$ati&ication o& .atients wit! +ent$icula$ a$$!)t!*ias o$ t!ose w!o a$e at $is4 o& %e+elo.in, li&e(t!$eatenin, +ent$icula$ a$$!)t!*ias0 Cu$$entl), onl) SA#C an%

%ia,nosin, t!e aetiolo,) o& an% in .$o,nosticatin, P@Cs0 T!e$&o$e it s!oul% /e .e$&o$*e% in .atients wit! sus.ecte% st$uctu$al !ea$t %isease an% in t!e su/set o& .atients at !i,! $is4 &o$ %e+elo.*ent o& se$ious +ent$icula$ a$$!)t!*ias o$ SC9, suc! as acute *)oca$%ial in&a$ction su$+i+o$s0 In ,ene$al, P@Cs in !ealt!) in%i+i%uals wit!out an) st$uctu$al !ea$t %isease %o not usuall) .ose an) $is4 o& SC90 T!e ACCDAFAD#SC 200< ,ui%elines &o$ t!e *ana,e*ent o& .atients wit! +ent$icula$ a$$!)t!*ias $eco**en%e% t!e e3e$cise st$ess test as a *eans o& un*as4in, +ent$icula$ a$$!)t!*ias %ue to isc!ae*ia o$ sus.ecte% catec!ola*ine(in%uce% +ent$icula$ a$$!)t!*ias0 It *a) /e consi%e$e% in t!e in+esti,ation o& isolate% P@Cs in *i%%le(a,e% o$ ol%e$ .atients wit!out ot!e$ e+i%ence o& CA90
(2=)

T6A testin, !a+e /een a..$o+e% /) t!e MS Foo% an% 9$u, A%*inist$ation0 In t!e e$a o& &i/$inol)sis o$ an,io.last) to in&a$ct a$te$), t!e use&ulness o& SA#C is li*ite% to /ein, a !i,! ne,ati+e .$e%icti+e +alue o& >9HK 99H to e3clu%e a wi%e(co*.le3 tac!)ca$%ia as a cause o& une3.laine% s)nco.e0(=') Si*ila$l), T6A testin, a..ea$s to !a+e a +e$) !i,! ne,ati+e .$e%icti+e accu$ac),(=5) t!us i*.$o+in, t!e %ia,nosis an% $is4 st$ati&ication o& !i,! $is4 .atients wit! +ent$icula$ a$$!)t!*ias0 (2=) reatment )or 01Cs Routine t$eat*ent wit! antia$$!)t!*ics is not wa$$ante%0 Most .atients wit! P@Cs a$e as)*.to*atic, an% $eassu$ance is t!e onl) t!e$a.) $e-ui$e% i& t!e$e is no e+i%ence o& st$uctu$al !ea$t %isease0 Fo$ s)*.to*atic .atients, a+oi%ance o& .$eci.itatin, &acto$s suc! as s*o4in,, e3cessi+e alco!ol an% ca&&eine inta4e *a)

#3e$cise testin, *a) .$o+i%e

.$o,nostic in&o$*ation in .atients wit! catec!ola*ine( in%uce% a$$!)t!*ias, ,i+en t!at t!e .$esence o& e3e$cise( in%uce% +ent$icula$ ecto.ic inc$eases *o$talit) at 12 *ont!s /) t!$ee(&ol% $elati+e to .atients wit! P@Cs at $est onl)0(=0) Fowe+e$, e3e$cise(in%uce% P@Cs in a..a$entl) no$*al in%i+i%uals s!oul% not /e use% to %ictate t!e$a.) unless associate% wit! %ocu*ente% isc!ae*ia o$ sustaine% @T0 #lect$o.!)siolo,) (#P) testin, !as /een use% &o$ a$$!)t!*ia assess*ent an% $is4 st$ati&ication &o$ SC9 since its int$o%uction in t!e ea$l) 19B0s0 Fowe+e$, #P testin, )iel% +a$ies, &un%a*entall) %e.en%ent on t!e 4in%

$e%uce t!e &$e-uenc) o& P@Cs0 8& ,$eate$ i*.o$tance is t!e e3clusion o& un%e$l)in, st$uctu$al !ea$t %isease o$ ot!e$ con%itions t!at *a) .$eci.itate P@Cs, suc! as elect$ol)te i*/alance o$ %$u, to3icit)0 A&te$ co$$ecta/le &acto$s !a+e /een a%%$esse%, *e%ications suc! as /eta( /loc4e$s can /e use% in t!e settin, o& a !).e$a%$ene$,ic state o$ *)oca$%ial isc!ae*ia i& t!e$e is a nee% to su..$ess t!e P@Cs0 Li,nocaine *a) /e use% %u$in, t!e .e$i(in&a$ct .e$io%0 In ,ene$al, e3e$cise(in%uce% P@Cs s!oul% not /e t$eate% $outinel) unless t!e$e is %ocu*ente% isc!ae*ia o$ sustaine% @T0 6it! t!e e3ce.tion o& /eta(/loc4e$s, t!e use o& antia$$!)t!*ic %$u,s to su..$ess e3e$cise( in%uce% P@Cs in ot!e$wise no$*al in%i+i%uals !as not /een s!own to /e e&&ecti+e in $e%ucin, SC90 Su..$ession o& as)*.to*atic P@Cs is no lon,e$ consi%e$e% a t!e$a.eutic ai* &o$ .$e+ention o& %eat! in .ost(in&a$ction o$ ca$%io*)o.at!) .atients0 So*e antia$$!)t!*ic %$u,s (suc! as &lecaini%e an% encaini%e) !a+e /een associate% wit! inc$ease% *o$talit) %ue to t!ei$ .$oa$$!)t!*ic .$o.e$ties in .atients wit! .$e+ious *)oca$%ial in&a$ction o$ un%e$l)in, CA90 I& an antia$$!)t!*ic is in%icate%, /eta(/loc4e$s a$e t!e &i$st(line &o$ su..$ession o& s)*.to*atic P@Cs0 T!e) !a+e /een conclusi+el) %e*onst$ate% to $e%uce *o$talit) in .ost(in&a$ction an% !ea$t &ailu$e .atients, an% t!us s!oul% /e .a$t o& t!e stan%a$% t!e$a.)0 T!e $ole o& a*io%a$one as a secon%(line antia$$!)t!*ic in t!is settin, is su..o$te% /) &in%in,s in t!e 5asel Antia$$!)t!*ic Stu%) o& In&a$ct Su$+i+al, w!ic! su,,este% t!at low(%ose a*io%a$one (i0e0 200 *,D%a)) in .atients wit! .e$sistin, as)*.to*atic co*.le3 a$$!)t!*ias a&te$ *)oca$%ial in&a$ction %ec$eases *o$talit) in t!e &i$st )ea$ a&te$ *)oca$%ial in&a$ction0(=<) T!is &in%in, was co$$o/o$ate% /) a late$ stu%), t!e Cana%ian A*io%a$one M)oca$%ial In&a$ction A$$!)t!*ia T$ial, in w!ic! t!e$e was '>05H $elati+e $is4 $e%uction o& a$$!)t!*ic %eat! o$ $esuscitate% +ent$icula$ &i/$illation, alt!ou,! no si,ni&icant %i&&e$ence in all(cause o$ ca$%iac *o$talit) was note%0(=B) A *eta( anal)sis in+ol+in, <,500 .ost(*)oca$%ial in&a$ction an% !ea$t &ailu$e .atients wit! a *e%ian &$e-uenc) o& P@Cs at 1> .e$ !ou$ %e*onst$ate% t!at a*io%a$one $esults in o+e$all $e%uction o& 1=H in total *o$talit)0(=>) To %ate, t!e t!e$a.) t!at /$in,s a/out t!e ,$eatest $e%uction in su%%en %eat! in .atients wit! low e;ection &$action is i*.lantation o& a ca$%io+e$te$(%e&i/$illato$0(=9) Ra%io&$e-uenc) a/lation is now a well($eco,nise%, non(.!a$*acolo,ical tec!ni-ue &o$ t!e eli*ination o& &$e-uent s)*.to*atic +ent$icula$ ecto.ic /eats w!en .!a$*acolo,ical t$eat*ent !as &aile% o$ is not .$e&e$$e%0 T!e 200< ACCDAFAD#SC ,ui%elines ,a+e t!is a Class IIa in%ication &o$ .atients w!o a$e ot!e$wise at low $is4 &o$

SC9 an% w!o !a+e &$e-uent s)*.to*atic, .$e%o*inantl) *ono*o$.!ic P@Cs t!at a$e %$u, $esistant, o$ &o$ t!ose w!o a$e %$u, intole$ant o$ %o not wis! to !a+e lon,( te$* %$u, t!e$a.)0 In a%%ition, a/lation o& as)*.to*atic P@Cs *a) also /e consi%e$e% w!en t!e P@Cs a$e +e$) &$e-uent, so as to a+oi% o$ t$eat tac!)ca$%ia(in%uce% ca$%io*)o.at!) (Class II/)0 (2=) A,S RAC -ow important are ".Cs an/ w#at s#oul/ we /o about t#em? ".Cs are not a /isease in t#emselves, but a mar0er o1 possible un/erlying con/itions t#at may increase t#e ris0 o1 car/iac /eat#& #ey serve as a 1lag to alert us to e2clu/e structural #eart /isease, t#e presence o1 w#ic# is t#e strongest pre/ictor o1 a/verse events& -owever, it is important to 0now t#at ".Cs are common in people wit# no structural #eart /isease& (n t#is situation, t#e prognosis is generally e2cellent& Suppression o1 ".Cs wit# antiarr#yt#mic me/ication is not in/icate/ routinely, unless t#e patient is symptomatic or at ris0 o1 tac#ycar/ia3 in/uce/ car/iomyopat#y owing to t#e very #ig# 1re4uency o1 ".Cs& 5#ere p#armacological t#erapy #as 1aile/, t#ere is now t#e option o1 ra/io1re4uency ablation 1or elimination o1 1re4uent symptomatic ".Cs& #e EC! is a simple yet use1ul tool to improve ris0 assessment, especially in t#ose wit# 0nown car/iovascular /isease& $eywor/s: premature ventricular comple2, su//en car/iac /eat#, syncope
Singapore Med J 2011; 52(10): 707-714

RE%ERE)CES
10 Ro)al Colle,e o& ene$al P$actitione$s0 A+aila/le at: ww w0$c,.0 o$,0u4Da/outNusD!isto$)N!e$ita,e a$c!i+esDa$c!i+esD.e$sonalN .a.e$sDsi$N;a*esN*ac4en:ieNcollectionD*ac4en:ieN/io,$a.!)0 as.30 Accesse% 9ece*/e$ 12, 200> Fiss R , L# La*/0 #lect$oca$%io,$a.!ic &in%in,s in 122,0'= in%i+i%uals0 Ci$culation 19<2; 25:9'B(<10 Mo$s!e%i(Mei/o%i A, #+ans EC, Le+) 9, La$son M , @asan RS0 Clinical co$$elates an% .$o,nostic si,ni&icance o& e3e$cise( in%uce% +ent$icula$ .$e*atu$e /eats in t!e co**unit): t!e F$a*in,!a* Fea$t Stu%)0 Ci$culation 200'; 109:2'1B(220 Si*.son RE E$, Cascio 6#, Sc!$eine$ PE, et al0 P$e+alence o& .$e*atu$e +ent$icula$ cont$actions in a .o.ulation o& A&$ican A*e$ican an% w!ite *en an% wo*en: t!e At!e$oscle$osis Ris4 in Co**unities (ARIC) stu%)0 A* Fea$t E 2002; 1'=:5=5('00 "enne%) FL, 6!itloc4 EA, S.$a,ue M", et al0 Lon,(te$* &ollow( u. o& as)*.to*atic !ealt!) su/;ects wit! &$e-uent an% co*.le3 +ent$icula$ ecto.)0 A #n,l E Me% 19>5; =12:19=(B0 #n,st$O* , Fe%/la% 5, Ean:on L, Euul(MOlle$ S0 @ent$icula$ a$$!)t!*ias %u$in, 2'(! a*/ulato$) #C $eco$%in,: inci%ence, $is4 &acto$s an% .$o,nosis in *en wit! an% wit!out a !isto$) o& ca$%io+ascula$ %isease0 E Inte$n Me% 1999; 2'<:=<=(B20

20 =0

'0

50

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B0 5i44ina M, La$son M , Le+) 90 P$o,nostic i*.lications o& as)*.to*atic +ent$icula$ a$$!)t!*ias: t!e F$a*in,!a* Fea$t Stu%)0 Ann Inte$n Me% 1992; 11B:990(<0 >0 A/%alla IS, P$ineas RE, Aeaton E9, Eaco/s 9R E$, C$ow RS0 Relation /etween +ent$icula$ .$e*atu$e co*.le3es an% su%%en ca$%iac %eat! in a..a$entl) !ealt!) *en0 A* E Ca$%iol 19>B; <0:10=<('20 90 Santini M, Ricci CP0 Cont$o+e$sies in t!e P$e+ention o& Su%%en 9eat!0 E Clin 5asic Ca$%iol 2001; ':2B5( >0 100 "ostis E5, 5)in,ton R, F$ie%*an LM, ol%stein S, Fu$/e$, C0 P$o,nostic si,ni&icance o& +ent$icula$ ecto.ic acti+it) in su$+i+o$s o& acute *)oca$%ial in&a$ction0 E A* Coll Ca$%iol 19>B; 10:2=1('20 110 Ru/e$*an 6, 6ein/latt #, ol%/e$, E9, et al0 @ent$icula$ .$e*atu$e co*.le3es an% su%%en %eat! a&te$ *)oca$%ial in&a$ction Ci$culation019>1; <':29B(=050 120 5i,,e$ ET E$, Fleiss EL, "lei,e$ R, Mille$ EP, Rolnit:4) LM0 T!e $elations!i.s a*on, +ent$icula$ a$$!)t!*ias, le&t +ent$icula$ %)s&unction, an% *o$talit) in t!e 2 )ea$s a&te$ *)oca$%ial in&a$ction0 Ci$culation 19>'; <9:250(>0 1=0 Fallst$o* AP, 5i,,e$ ET E$, Ro%en 9, et al0 P$o,nostic si,ni&icance o& +ent$icula$ .$e*atu$e %e.ola$i:ations *easu$e% 1 )ea$ a&te$ *)oca$%ial in&a$ction in .atients wit! ea$l) .ostin&a$ction as)*.to*atic +ent$icula$ a$$!)t!*ia0 E A* Coll Ca$%iol 1992; 20:259(<'0 1'0 Cali&& RM, Mc"innis RA, 5u$4s E, et al P$o,nostic i*.lications o& +ent$icula$ a$$!)t!*ias %u$in, 2' !ou$ a*/ulato$) *onito$in, in .atients un%e$,oin, ca$%iac cat!ete$i:ation &o$ co$ona$) a$te$) %isease0 A* E Ca$%iol 19>2; 50:2=(=10 150 Po%$i% PE, Fo,el RI, Fuc!s TT0 @ent$icula$ a$$!)t!*ia in con,esti+e !ea$t &ailu$e0 A* E Ca$%iol 1992; <9:>2 (95 ; %iscussion 95 (9< 0 1<0 Pa$tin,ton S, M)e$s E, C!o S, F$oelic!e$ @, C!un S0 P$e+alence an% .$o,nostic +alue o& e3e$cise(in%uce% +ent$icula$ a$$!)t!*ias0 A* Fea$t E 200=; 1'5:1=9('<0 1B0 Eou+en P, Qu$ei4 M, 9esnos M, Cou$/on 9, 9uci*etiR$e P0 Lon,(te$* outco*e in as)*.to*atic *en wit! e3e$cise(in%uce% .$e*atu$e +ent$icula$ %e.ola$i:ations0 A #n,l E Me% 2000; ='=:>2<(==0 1>0 F$ol4is EP, Pot!ie$ C#, 5lac4stone #F, Laue$ MS0 F$e-uent +ent$icula$ ecto.) a&te$ e3e$cise as a .$e%icto$ o& %eat!0 A #n,l E Me% 200=; ='>:B>1(900 190 C!ian, 5A, Pe$l*an L@, 8st$an%e$ L9 E$, #.stein FF0 Relations!i. o& .$e*atu$e s)stoles to co$ona$) !ea$t %isease an% su%%en %eat! in t!e Tecu*se! e.i%e*iolo,ic stu%)0 Ann Inte$n Me% 19<9; B0:1159(<<0 200 + a n 5 e * * e l T, @i n 4 e $ s 9E, Ma c & a $ l a n e P6, u sse 4 l o o E, 6esten%o$. R 0 Ma$4e$s o& autono*ic tone on a stan%a$% #C a$e .$e%icti+e o& *o$talit) in ol% a,e0 Int E Ca$%iol 200<; 10B:=<('10 210 Fle, EL, "enne%) FL0 Lon,(te$* .$o,nostic si,ni&icance o& a*/ulato$) elect$oca$%io,$a.!ic &in%in,s in a..a$entl) !ealt!) su/;ects ,$eate$ t!an o$ e-ual to <0 )ea$s o& a,e0 A* E Ca$%iol 1992; B0:B'>(510 220 A%a/a, AS, Case) SA, "us4ows4i MA, Qeno+ic! A , Ma$on 5E0 S.ect$u* an% .$o,nostic si,ni&icance o& a$$!)t!*ias on a*/ulato$) Folte$ elect$oca$%io,$a* in !).e$t$o.!ic ca$%io*)o.at!)0 E A* Coll Ca$%iol 2005; '5:<9B(B0'0 2=0 #u$o.ean Fea$t R!)t!* Association, Fea$t R!)t!* Societ), Qi.es 9P, et al0 ACCDAFAD#SC 200< ,ui%elines &o$ *ana,e*ent o& .atients wit! +ent$icula$ a$$!)t!*ias an% t!e .$e+ention o& su%%en ca$%iac %eat!: a $e.o$t o& t!e A*e$ican Colle,e o& Ca$%iolo,)D

A*e$ican Fea$t Association Tas4 Fo$ce an% t!e #u$o.ean Societ) o& Ca$%iolo,) Co**ittee &o$ P$actice ui%elines (6$itin, Co**ittee to 9e+elo. ui%elines &o$ Mana,e*ent o& Patients 6it! @ent$icula$ A$$!)t!*ias an% t!e P$e+ention o& Su%%en Ca$%iac 9eat!)0 E A* Coll Ca$%iol 200<; '>:e2'B(='<0 2'0 Ao%a T, S!i*i:u 6, Ta,uc!i A, et al0 Mali,nant entit) o& i%io.at!ic +ent$icula$ &i/$illation an% .ol)*o$.!ic +ent$icula$ tac!)ca$%ia initiate% /) .$e*atu$e e3t$as)stoles o$i,inatin, &$o* t!e $i,!t +ent$icula$ out&low t$act0 E A* Coll Ca$%iol 2005; '<:12>>(9'0 250 a$son A E$0 @ent$icula$ a$$!)t!*ias a&te$ $e.ai$ o& con,enital !ea$t %isease: w!o nee%s t$eat*ent7 Ca$%iol Soun, 1991; 1:1BB( >10 2<0 Qi.es 9P, Ac4e$*an ME, #stes AA =$%, et al0 Tas4 Fo$ce B: a$$!)t!*ias0 E A* Coll Ca$%iol 2005; '5:1=5'( <=0 2B0 "o$s EA, %e 5$u)ne MC, Foes A6, +an Fe$.en , et al0 T a3is as an in%icato$ o& $is4 o& ca$%iac e+ents in el%e$l) .eo.le0 Lancet 199>; =52:<01(50 2>0 Sc!outen # , 9e44e$ EM, Me..elin4 P, et al0 GT inte$+al .$olon,ation .$e%icts ca$%io+ascula$ *o$talit) in an a..a$entl) !ealt!) .o.ulation0 Ci$culation 1991; >':151<(2=0 290 ussa4 I, 5$u,a%a P, 5$u,a%a E, et al0 I%io.at!ic s!o$t GT inte$+al: a new clinical s)n%$o*e7 Ca$%iolo,) 2000; 9':99( 1020 =00 Po%$i% PE, $a/o)s T50 #3e$cise st$ess testin, in t!e *ana,e*ent o& ca$%iac $!)t!* %iso$%e$s0 Me% Clin Ao$t! A* 19>'; <>:11=9(520 =10 5ac!ins4) 65, Lin:e$ M, 6el% L, #stes AA =$%0 Mse&ulness o& clinical c!a$acte$istics in .$e%ictin, t!e outco*e o& elect$o.!)siolo,ic stu%ies in une3.laine% s)nco.e0 A* E Ca$%iol 1992; <9:10''(90 =20 Moss AE, Fall 6E, Canno* 9S, et al0 I*.$o+e% su$+i+al wit! an i*.lante% %e&i/$illato$ in .atients wit! co$ona$) %isease at !i,! $is4 &o$ +ent$icula$ a$$!)t!*ia0 Multicente$ Auto*atic 9e&i/$illato$ I*.lantation T$ial In+esti,ato$s0 A #n,l E Me% 199<; ==5:19==('00 ==0 Ito S, Ta%a F, Aaito S, et al0 9e+elo.*ent an% +ali%ation o& an #C al,o$it!* &o$ i%enti&)in, t!e o.ti*al a/lation site &o$ i%io.at!ic +ent$icula$ out&low t$act tac!)ca$%ia0 E Ca$%io+asc #lect$o.!)siol 200=; 1':12>0(<0 ='0 Stein/e$, ES, P$)stows4) #, F$ee%*an RA, et al0 Mse o& t!e si,nal( a+e$a,e% elect$oca$%io,$a* &o$ .$e%ictin, in%uci/le +ent$icula$ tac!)ca$%ia in .atients wit! une3.laine% s)nco.e: $elation to clinical +a$ia/les in a *ulti+a$iate anal)sis0 E A* Coll Ca$%iol 199'; 2=:99(10<0 =50 5loo*&iel% 9M, 5i,,e$ ET, Stein*an RC, et al0 Mic$o+olt T( wa+e alte$nans an% t!e $is4 o& %eat! o$ sustaine% +ent$icula$ a$$!)t!*ias in .atients wit! le&t +ent$icula$ %)s&unction0 E A* Coll Ca$%iol 200<; 'B:'5<(<=0 =<0 5u$4a$t F, P&iste$e$ M, "iows4i 6, Follat! F, 5u$c4!a$%t 90 #&&ect o& antia$$!)t!*ic t!e$a.) on *o$talit) in su$+i+o$s o& *)oca$%ial in&a$ction wit! as)*.to*atic co*.le3 +ent$icula$ a$$!)t!*ias: 5asel Antia$$!)t!*ic Stu%) o& In&a$ct Su$+i+al (5ASIS)0 E A* Coll Ca$%iol 1990; 1<:1B11(>0 =B0 Cai$ns EA, Connoll) SE, Ro/e$ts R, ent M0 Ran%o*ise% t$ial o& outco*e a&te$ *)oca$%ial in&a$ction in .atients wit! &$e-uent o$ $e.etiti+e +ent$icula$ .$e*atu$e %e.ola$isations: CAMIAT0 Cana%ian A*io%a$one M)oca$%ial In&a$ction A$$!)t!*ia T$ial In+esti,ato$s0 Lancet 199B; ='9:<B5(>20 =>0 #&&ect o& .$o.!)lactic a*io%a$one on *o$talit) a&te$ acute *)oca$%ial in&a$ction an% in con,esti+e !ea$t &ailu$e: *eta( anal)sis o& in%i+i%ual %ata &$o* <500 .atients in $an%o*ise% t$ials0 A*io%a$one T$ials Meta(Anal)sis In+esti,ato$s0 Lancet 199B; =50:1'1B(2'0

S()!A"ORE ME+(CAL CO*)C(L CA E!OR6 7, CME "RO!RAMME Multiple C#oice 8uestions 9Co/e SM: ;<'''<A=

42estion 15 Re,a$%in, .$e*atu$e +ent$icula$ co*.le3 (P@C): (a) P@Cs a$e one o& t!e *ost co**on a$$!)t!*ias an% can occu$ in .atients wit! o$ wit!out un%e$l)in, !ea$t %isease0 (/) T!e .$esence an% se+e$it) o& un%e$l)in, st$uctu$al !ea$t %isease is not t!e *ost i*.o$tant %ete$*inant o& its .$o,nostic si,ni&icance0 (c) Recent la$,e .o.ulation(/ase% stu%) /) Massin, et al s!owe% !ealt!) .atients wit! P@Cs we$e *o$e t!an two ti*es as li4el) to %ie %ue to co$ona$) !ea$t %isease t!an t!ose wit!out P@Cs0 (%) P@C can /e a si,n o& esta/lis!e% co$ona$) a$te$) %isease, wit! a .$e+alence o& 5>H in *en0

r2e

6alse

42estion &5 Re,a$%in, P@C in .ost *)oca$%ial in&a$ction: (a) T!e .$esence o& *o$e t!an ten P@Cs an !ou$ .$io$ to %isc!a$,e a&te$ *)oca$%ial in&a$ction was associate% wit! <H *o$talit)0 (/) Pol)*o$.!ic P@Cs connote a .oo$e$ .$o,nosis t!an uni&o$* *o$.!olo,ic P@Cs0 (c) T!e .$esence o& co*.le3 P@Cs (%e&ine% as 1R on T2, $uns o& two o$ *o$e, *ulti&o$* o$ /i,e*inal co*.le3e s)

con&e$$e% a $is4 o& ca$%iac %eat!0 (%) T!e .$esence o& P@Cs a&te$ acute *)oca$%ial in&a$ction is not associate% wit! inc$ease% total *o$talit), .a$ticula$l) in t!ose wit! i*.ai$e% le&t +ent$icula$ &unction0 42estion 75 Re,a$%in, e3e$cise(in%uce% P@Cs: (a) T!e .$o/a/le *ec!anis*s &o$ P@Cs inclu%e en!ance% auto*aticit), $e(ent$) an% t$i,,e$e% acti+it)0 (/) P@Cs %u$in, e3e$cise a$e associate% wit! an inc$ease in all(cause *o$talit) i$$es.ecti+e o& t!e .$esence o& ca$%io.ul*ona$) %isease o$ e3e$cise(in%uce% isc!ae*ia0 (c) F$e-uent P@Cs %u$in, t!e $eco+e$) .!ase o& t!e e3e$cise st$ess test was a st$on,e$ .$e%icto$ o& an inc$ease% $is4 o&

*o$talit)0 (%) T!e$e is an association /etween e3e$cise(in%uce% P@Cs an% ca$%io+ascula$ *o$talit), /ut t!e e3tent o& its clinical i*.lication in as)*.to*atic in%i+i%uals wit! st$uctu$all) no$*al !ea$ts is as )et unce$tain0 42estion 85 Re,a$%in, *ana,e*ent o& P@Cs: (a) T!e *a;o$ %ete$*inants o& $is4 o& su%%en ca$%iac %eat! (SC9) a$e $elate% *o$e to t!e t).e an% se+e$it) o& associate% ca$%iac %isease an% less to t!e &$e-uenc) o$ classi&ication o& +ent$icula$ a$$!)t!*ia0 (/) A .ositi+e &a*il) !isto$) o& SC9 is not a st$on, in%e.en%ent .$e%icto$ o& susce.ti/ilit) to SC90 (c) #c!oca$%io,$a.!) is use&ul &o$ %ete$*inin, t!e .$esence o$ a/sence o& st$uctu$al !ea$t %isease as well to assess

ca$%iac &unction0 (%) #3e$cise st$ess test as a *eans o& un*as4in, +ent$icula$ a$$!)t!*ias %ue to isc!ae*ia o$ sus.ecte% catec!ola*ine in%uces +ent$icula$ a$$!)t!*ias0

42estion *5 Re,a$%in, t$eat*ent o& P@Cs: (a) Routine t$eat*ent wit! antia$$!)t!*ic %$u, is wa$$ante%0 (/) In s)*.to*atic .atients, a+oi%ance o& .$eci.itatin, &acto$s suc! as s*o4in,, e3cessi+e alco!ol an% ca&&eine inta4e !el.s0 (c) Antia$$!)t!*ic %$u,s (suc! as &lecaini%e, encaini%e) !a+e /een associate% wit! inc$ease% *o$talit) %ue to t!e i$

.$oa$$!)t!*ic .$o.e$ties in .atients wit! un%e$l)in, co$ona$) a$te$) %isease0 (%) Ra%io&$e-uenc) a/lation is now a well($eco,nise%, non(.!a$*acolo,ical tec!ni-ue &o$ t!e eli*ination o& &$e-uent s)*.to*atic +ent$icula$ ecto.ic /eats w!en .!a$*acolo,ical t$eat*ent !as &aile% o$ is not .$e&e$$e%0
Doctor9s partic2lars/ Aa*e in &ull: MCR nu*/e$: #*ail a%%$ess:

NS.ecialt):

SU"M:SS:;N :NS RUC :;NS/ (1) Lo, on at t!e SME we/site: !tt.:DDww w0s*a0o$,0s,Dc*eDs* ; an% select t!e a..$o.$iate set o& -uestions0 (2) Select )ou$ answe$s an% .$o+i%e )ou$ na*e, e*ail a%%$ess an% MCR nu*/e$0 Clic4 on 1Su/*it answe$s2 to

su/*it0 RESU$ S/ (1) Answe$s will /e .u/lis!e% in t!e SME 9ece*/e$ 2011 issue0 (2) T!e MCR nu*/e$s o& success&ul can%i%ates will /e .oste% online at www0s*a0o $,0s,Dc*eDs* ; /) 1> Ao+e*/e$ 20110 (=) All online su/*issions will $ecei+e an auto*atic e*ail ac4nowle%,*ent0 (') Passin, *a$4 is <0H0 Ao *a$4 will /e %e%ucte% &o$ inco$$ect answe$s0 (5) T!e SME e%ito$ial o&&ice will su/*it t!e list o& success&ul can%i%ates to t!e Sin,a.o$e Me%ical Council0 Deadline )or s2<mission/ =;cto<er &-11 SMJ 7" CME programme>/ 1& noon, 11 Novem<er &-115