New electrocardiographic criteria for discriminating between Brugada types 2 and 3 patterns and incomplete right bundle branch block.

OBJECTIVES: The aim of this study was to evaluate new electrocardiographic (ECG) criteria for discriminating between incomplete right bundle branch block (RBBB) and the Brugada types 2 and 3 ECG patterns. BACKGROUND: Brugada syndrome can manifest as either type 2 or type 3 pattern. The latter should be distinguished from incomplete RBBB, present in 3% of the population. METHODS: Thirty-eight patients with either type 2 or type 3 Brugada pattern that were referred for an antiarrhythmic drug challenge (AAD) were included. Before AAD, 2 angles were measured from ECG leads V(1) and/or V(2) showing incomplete RBBB: 1) α, the angle between a vertical line and the downslope of the r'-wave, and 2) ß, the angle between the upslope of the S-wave and the downslope of the r'-wave. Baseline angle values, alone or combined with QRS duration, were compared between patients with negative and positive results on AAD. Receiver-operating characteristic curves were constructed to identify optimal discriminative cutoff values. RESULTS: The mean ß angle was significantly smaller in the 14 patients with negative results on AAD compared to the 24 patients with positive results on AAD (36 ± 20° vs. 62 ± 20°, p < 0.01). Its optimal cutoff value was 58°, which yielded a positive predictive value of 73% and a negative predictive value of 87% for conversion to type 1 pattern on AAD; α was slightly less sensitive and specific compared with ß. When the angles were combined with QRS duration, it tended to improve discrimination. CONCLUSIONS: In patients with suspected Brugada syndrome, simple ECG criteria can enable discrimination between incomplete RBBB and types 2 and 3 Brugada patterns.

Involvement of P2Y receptors in pyridoxal-5'-phosphate-induced cardiac preconditioning.

Using an isolated non-working rat heart model, this study investigated the mechanisms of pharmacological pre-conditioning (PC) induced by P2Y receptor stimulation with pyridoxal-5'-phosphate (PLP). After 6-hydroxydopamine pretreatment and a 15-min stabilization period, isolated rat hearts were perfused for 25 min then subjected to 40 min of global ischemia and 30 min of reperfusion (I/R); exposed for 15 min to 0.05 microM PLP bracketed for 25 min with broad-spectrum P2 antagonists (suramin or PPADS) or with more specific P2Y antagonists (AMPalphaS or MRS2578), 1 microM each, followed by a 5-min PLP-free perfusion before I/R; treated during 25 min with either glybenclamide (GLY, 1 microM), 5-hydroxydecanoic acid (5-HD, 100 microM), U73122 (0.5 microM), H89 (1 microM), or KN93 (1 microM), with an infusion starting 5 min before PLP. The main endpoints were the rate-pressure product (RPP), creatine kinase (CK) release and area necrosis. Recovery of RPP, measured 5 min after reperfusion, was rapidly improved by PLP, blocked by the P2 antagonists, and decreased with the different inhibitors. Fifteen minutes after the end of ischemia, CK release reached maximal values in all groups. PLP provided significant protection, whereas the P2 antagonists, 5-HD, a mitochondrial selective K(ATP) antagonist and GLY a non-selective K(ATP) channel blocker, suppressed the protective effect on myocardial injury. The suppression of the cardioprotective effects of PLP by AMPalphaS, the PKA inhibitor (H89), and phospholipase C blocker (U73122) is in agreement with the P2Y11 receptor as a receptor for PLP-induced PC. The suppression of the cardioprotective effects of PLP by MRS2578 and U73122 is in agreement with the P2Y6 receptor as a receptor for PLP-induced PC. Pre-ischemic exposure to nanomolar concentrations of PLP is protective against I/R. P2Y11 and P2Y6 represents the most likely candidate receptors for PLP-induced cardiac PC.

[Lumbar puncture]. / Ponction lombaire.

Lumbar puncture (LP) is a procedure frequently performed by internists. The aim of this article is to describe in detail the procedure, to give some practical advices to always succeed in doing a lumbar puncture and to discuss the most frequent complications, how to prevent them and how to treat them. We will also answer some frequently asked questions, such as indications to perform neuroimaging before a lumbar puncture, or patient mobilisation after LP. Knowledge of these points is key to give a complete information to the patients and obtain an informed consent.