REPOLARIZAÇÃO PRECOCE: QUANDO É UM MARCADOR DE RISCO?
Autor: Nestor Rodrigues de Oliveira Neto | Publicado: 2016-08-20T18:07:00-07:00








ECG DE JOVEM COM PADRÃO DE REPOLARIZAÇÃO PRECOCE.




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A DIFERENÇA ENTRE OS POTENCIAIS É
RELACIONADA À ARRITMOGÊNESE.&nbsp;

CONFORME ALGUNS, A SÍNDROME DE BRUGADA SERIA UM EXTREMO DESTE MECANISMO.




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Jp ou
início do retardo ≤ 0,1 mV (1
mm) em duas derivações relacionadas, exceto V1 a V3.&nbsp;

No exemplo:&nbsp;Jp=2,5
mm e início do retardo=3,5 mm.




Historicamente, a repolarização
precoce (RP) era considerada um marcador de boa saúde, por estar presente em
jovens e atletas. Os livros de eletrocardiografia consideravam a RP como
variante do normal, sem relação com risco cardíaco. 

A repolarização precoce tem como
característica a elevação do segmento ST, com pequena concavidade superior,
associado a ondas T amplas, assimétricas. O final do complexo QRS exibe um
entalhe (onda J) ou “empastamento”.

Em 2008, dois estudos foram
publicados (Haissaguerre et al e Rosso et al), com evidências de uma maior
prevalência de RP em pessoas acometidas por fibrilação ventricular (FV)
primária. No estudo de Rosso et al, a prevalência de RP foi de 31% nos 45
pacientes acometidos por FV primária e de 9% no grupo controle (124 pessoas):
OR=3,2; p=0,002. 

Essa diferença entre o grupo com
história de FV e o grupo controle foi observada para a RP nas derivações
inferiores (DII, DIII e aVF) ou laterais (DI e aVL), porém a elevação do ponto
J ocorreu em igual frequência, em V4 a V6.

A definição de RP tem variado
entre os estudos. Um consenso foi publicado recentemente, visando uniformizar
os critérios para a caracterização deste padrão. A RP está presente quando todos
os seguintes critérios são encontrados:

1.&nbsp;&nbsp; Presença de entalhe ou retardo (empastamento) no ramo descente da
onda R. O entalhe deve se localizar acima da linha de base, bem como o início
do empastamento no final da onda R.

2.&nbsp;&nbsp; O pico do entalhe no final do QRS (onda J), ou o início do retardo
no final do QRS, deve ser ≥ 0,1 mV em duas ou mais derivações relacionadas,
exceto V1 a V3.

3.&nbsp;&nbsp; A duração do QRS deve ser &lt; 120 ms.

Portanto, conforme este consenso,
a elevação isolada do segmento ST, na ausência de entalhe ou retardo
(empastamento) no ramo descente da onda R, não deve ser descrita como
repolarização precoce. Estes padrões, tais como o chamado padrão masculino&nbsp;(elevação do ST em nas precordiais V1-V4), podem ser considerados como variante da
normalidade.&nbsp;

Na maioria dos casos a
repolarização precoce é uma condição benigna. Principalmente a forma limitada
às derivações precordiais V4 a V6.

De modo geral, um paciente com RP
apresenta bom prognóstico, desde que este é um padrão frequente, enquanto
a morte súbita por fibrilação ventricular é muito rara. A prevalência de padrão de RP na
população geral varia 5 a 13%.
Por outro lado, o supradesnível de ST
observado na RP ou como padrão variante da normalidade é causa de confusão com
infarto agudo do miocárdio nas unidades de emergência.
A existência de um potencial de
ação proeminente no epicárdio, causada por uma corrente transitória de potássio
para o extracelular (Ito), mas que é ausente no endocárdio, cria um gradiente elétrico
na fase de repolarização precoce, o que se traduz pela onda J observada no ECG.
A diferença na distribuição desta corrente Ito pode ser um fator para a gênese
das arritmias ventriculares malignas.

A síndrome de repolarização precoce compartilha algumas características comuns com a síndrome de Brugada: predomínio no sexo masculino, eventos mais durante o sono e alteração do ponto J. Entretanto, ao contrário do que ocorre em Brugada, o padrão de &nbsp;RP não é induzido por drogas antiarrítmicas do grupo 1, como ajmalina e procainamida.

Um curso benigno da repolarização
precoce foi demonstrado em um estudo de seguimento de 23 anos, com ausência de
aumento na mortalidade após análise multivariado e com frequente regressão do
padrão no decorrer do tempo.

A RP apresenta um risco maior quando há história pessoal de síncope ou
morte súbita recuperada, ou história familiar de morte cardíaca prematura. E quando envolve as derivações inferiores e/ou
laterais e, possivelmente, com ST horizontal ou descendente.

Portanto, duas condições distintas devem ser consideradas:


Síndrome
da repolarização precoce: elevação do ponto J ≥ 0,1 mV
em duas derivações relacionadas, inferior ou lateral, com um entalhe ou
empastamento do QRS, em pacientes com relato morte súbita recuperada, FV
documentada ou taquicardia ventricular polimórfica, ou com um padrão familiar
(mutação genética).
Padrão
de repolarização precoce: presença da alteração
eletrocardiográfica: elevação do ponto J ≥ 0,1 mV em duas derivações
relacionadas, inferior ou lateral, com um entalhe (onda J) ou empastamento no
final do QRS.


Não se recomenda nenhuma
investigação diagnóstica adicional quando o padrão de repolarização precoce é
observado, isto é, na ausência de história pessoal de síncope ou morte súbita recuperada
e na ausência de história familiar de morte cardíaca prematura.







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REFERÊNCIAS

<!--[if !supportLists]-->1.&nbsp;&nbsp;&nbsp;&nbsp;
<!--[endif]-->Haïssaguerre M, Derval N, Sacher F, et al.
Sudden cardiac arrest associated with early repolarization. N Engl J Med. 2008;
358(19):2016-23). 

<!--[if !supportLists]-->2.&nbsp;&nbsp;&nbsp;&nbsp;
<!--[endif]-->Rosso R, Kogan E, Belhassen B, et al. J-point
elevation in survivors of primary ventricular fibrillation and matched control
subjects: incidence and clinical significance. J Am Coll Cardiol.
2008;52(15):1231-8.

<!--[if !supportLists]-->3.&nbsp;&nbsp;&nbsp;&nbsp;
<!--[endif]-->Patel RB, Ng J, Reddy V, et al. Early
repolarization associated with ventricular arrhythmias in patients with chronic
coronary artery disease. Circ Arrhythm Electrophysiol 2010; 3:489.

<!--[if !supportLists]-->4.&nbsp;&nbsp;&nbsp;&nbsp;
<!--[endif]-->Macfarlane M, Antzelevitch C, Haïssaguerre M, et
al. The early repolarization pattern: a consensus paper. J Am Coll Cardiol
2015; 66 (4):470-7. 

<!--[if !supportLists]-->5.&nbsp;&nbsp;&nbsp;&nbsp;
<!--[endif]-->Yan GX, Antzelevitch C. Cellular basis for the
electrocardiographic J wave. Circulation 1996;93:372–9.

<!--[if !supportLists]-->6.&nbsp;&nbsp;&nbsp;&nbsp;
<!--[endif]-->Ilkhanoff L, Soliman EZ, Prineas RJ, et al.
Clinical characteristics and outcomes associated with the natural history of
early repolarization in a young, biracial cohort followed to middle age: The
Coronary Artery Risk Development in Young Adults (CARDIA) Study. Circ Arrhythm
Electrophysiol. 2014;7(3):392-9. 

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<!--[if !supportLists]-->7.&nbsp;&nbsp;&nbsp;&nbsp;
<!--[endif]-->Tikkanen JT. Editorial: The phenomenon of early
repolarization: a false alarm? (Circ Arrhythm Electrophysiol. 2014;7:368-369. 

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  <w:LsdException Locked="false" Priority="11" SemiHidden="false"
   UnhideWhenUsed="false" QFormat="true" Name="Subtitle"/>
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   UnhideWhenUsed="false" QFormat="true" Name="Strong"/>
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   UnhideWhenUsed="false" QFormat="true" Name="Emphasis"/>
  <w:LsdException Locked="false" Priority="59" SemiHidden="false"
   UnhideWhenUsed="false" Name="Table Grid"/>
  
  <w:LsdException Locked="false" Priority="1" SemiHidden="false"
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   UnhideWhenUsed="false" Name="Light Shading"/>
  <w:LsdException Locked="false" Priority="61" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light List"/>
  <w:LsdException Locked="false" Priority="62" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light Grid"/>
  <w:LsdException Locked="false" Priority="63" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Shading 1"/>
  <w:LsdException Locked="false" Priority="64" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Shading 2"/>
  <w:LsdException Locked="false" Priority="65" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium List 1"/>
  <w:LsdException Locked="false" Priority="66" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium List 2"/>
  <w:LsdException Locked="false" Priority="67" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Grid 1"/>
  <w:LsdException Locked="false" Priority="68" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Grid 2"/>
  <w:LsdException Locked="false" Priority="69" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Grid 3"/>
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   UnhideWhenUsed="false" Name="Dark List"/>
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   UnhideWhenUsed="false" Name="Colorful Shading"/>
  <w:LsdException Locked="false" Priority="72" SemiHidden="false"
   UnhideWhenUsed="false" Name="Colorful List"/>
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   UnhideWhenUsed="false" Name="Colorful Grid"/>
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   UnhideWhenUsed="false" Name="Light Shading Accent 1"/>
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   UnhideWhenUsed="false" Name="Light List Accent 1"/>
  <w:LsdException Locked="false" Priority="62" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light Grid Accent 1"/>
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   UnhideWhenUsed="false" Name="Medium Shading 1 Accent 1"/>
  <w:LsdException Locked="false" Priority="64" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Shading 2 Accent 1"/>
  <w:LsdException Locked="false" Priority="65" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium List 1 Accent 1"/>
  
  <w:LsdException Locked="false" Priority="34" SemiHidden="false"
   UnhideWhenUsed="false" QFormat="true" Name="List Paragraph"/>
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   UnhideWhenUsed="false" QFormat="true" Name="Quote"/>
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   UnhideWhenUsed="false" Name="Medium List 2 Accent 1"/>
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   UnhideWhenUsed="false" Name="Medium Grid 1 Accent 1"/>
  <w:LsdException Locked="false" Priority="68" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Grid 2 Accent 1"/>
  <w:LsdException Locked="false" Priority="69" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Grid 3 Accent 1"/>
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   UnhideWhenUsed="false" Name="Dark List Accent 1"/>
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   UnhideWhenUsed="false" Name="Colorful Shading Accent 1"/>
  <w:LsdException Locked="false" Priority="72" SemiHidden="false"
   UnhideWhenUsed="false" Name="Colorful List Accent 1"/>
  <w:LsdException Locked="false" Priority="73" SemiHidden="false"
   UnhideWhenUsed="false" Name="Colorful Grid Accent 1"/>
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   UnhideWhenUsed="false" Name="Light Shading Accent 2"/>
  <w:LsdException Locked="false" Priority="61" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light List Accent 2"/>
  <w:LsdException Locked="false" Priority="62" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light Grid Accent 2"/>
  <w:LsdException Locked="false" Priority="63" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Shading 1 Accent 2"/>
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   UnhideWhenUsed="false" Name="Medium Shading 2 Accent 2"/>
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   UnhideWhenUsed="false" Name="Medium List 2 Accent 2"/>
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   UnhideWhenUsed="false" Name="Colorful Grid Accent 2"/>
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   UnhideWhenUsed="false" Name="Light List Accent 3"/>
  <w:LsdException Locked="false" Priority="62" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light Grid Accent 3"/>
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   UnhideWhenUsed="false" Name="Medium Shading 1 Accent 3"/>
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   UnhideWhenUsed="false" Name="Medium List 1 Accent 3"/>
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   UnhideWhenUsed="false" Name="Medium List 2 Accent 3"/>
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   UnhideWhenUsed="false" Name="Dark List Accent 3"/>
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   UnhideWhenUsed="false" Name="Colorful List Accent 3"/>
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   UnhideWhenUsed="false" Name="Colorful Grid Accent 3"/>
  <w:LsdException Locked="false" Priority="60" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light Shading Accent 4"/>
  <w:LsdException Locked="false" Priority="61" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light List Accent 4"/>
  <w:LsdException Locked="false" Priority="62" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light Grid Accent 4"/>
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   UnhideWhenUsed="false" Name="Medium Shading 1 Accent 4"/>
  <w:LsdException Locked="false" Priority="64" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Shading 2 Accent 4"/>
  <w:LsdException Locked="false" Priority="65" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium List 1 Accent 4"/>
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   UnhideWhenUsed="false" Name="Medium Grid 3 Accent 4"/>
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   UnhideWhenUsed="false" Name="Dark List Accent 4"/>
  <w:LsdException Locked="false" Priority="71" SemiHidden="false"
   UnhideWhenUsed="false" Name="Colorful Shading Accent 4"/>
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   UnhideWhenUsed="false" Name="Colorful List Accent 4"/>
  <w:LsdException Locked="false" Priority="73" SemiHidden="false"
   UnhideWhenUsed="false" Name="Colorful Grid Accent 4"/>
  <w:LsdException Locked="false" Priority="60" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light Shading Accent 5"/>
  <w:LsdException Locked="false" Priority="61" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light List Accent 5"/>
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   UnhideWhenUsed="false" Name="Light Grid Accent 5"/>
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   UnhideWhenUsed="false" Name="Medium Shading 1 Accent 5"/>
  <w:LsdException Locked="false" Priority="64" SemiHidden="false"
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   UnhideWhenUsed="false" Name="Medium List 2 Accent 5"/>
  <w:LsdException Locked="false" Priority="67" SemiHidden="false"
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   UnhideWhenUsed="false" Name="Medium Grid 2 Accent 5"/>
  <w:LsdException Locked="false" Priority="69" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Grid 3 Accent 5"/>
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   UnhideWhenUsed="false" Name="Dark List Accent 5"/>
  <w:LsdException Locked="false" Priority="71" SemiHidden="false"
   UnhideWhenUsed="false" Name="Colorful Shading Accent 5"/>
  <w:LsdException Locked="false" Priority="72" SemiHidden="false"
   UnhideWhenUsed="false" Name="Colorful List Accent 5"/>
  <w:LsdException Locked="false" Priority="73" SemiHidden="false"
   UnhideWhenUsed="false" Name="Colorful Grid Accent 5"/>
  <w:LsdException Locked="false" Priority="60" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light Shading Accent 6"/>
  <w:LsdException Locked="false" Priority="61" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light List Accent 6"/>
  <w:LsdException Locked="false" Priority="62" SemiHidden="false"
   UnhideWhenUsed="false" Name="Light Grid Accent 6"/>
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   UnhideWhenUsed="false" Name="Medium Shading 1 Accent 6"/>
  <w:LsdException Locked="false" Priority="64" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Shading 2 Accent 6"/>
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   UnhideWhenUsed="false" Name="Medium List 1 Accent 6"/>
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   UnhideWhenUsed="false" Name="Medium List 2 Accent 6"/>
  <w:LsdException Locked="false" Priority="67" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Grid 1 Accent 6"/>
  <w:LsdException Locked="false" Priority="68" SemiHidden="false"
   UnhideWhenUsed="false" Name="Medium Grid 2 Accent 6"/>
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   UnhideWhenUsed="false" Name="Medium Grid 3 Accent 6"/>
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   UnhideWhenUsed="false" Name="Dark List Accent 6"/>
  <w:LsdException Locked="false" Priority="71" SemiHidden="false"
   UnhideWhenUsed="false" Name="Colorful Shading Accent 6"/>
  <w:LsdException Locked="false" Priority="72" SemiHidden="false"
   UnhideWhenUsed="false" Name="Colorful List Accent 6"/>
  <w:LsdException Locked="false" Priority="73" SemiHidden="false"
   UnhideWhenUsed="false" Name="Colorful Grid Accent 6"/>
  <w:LsdException Locked="false" Priority="19" SemiHidden="false"
   UnhideWhenUsed="false" QFormat="true" Name="Subtle Emphasis"/>
  <w:LsdException Locked="false" Priority="21" SemiHidden="false"
   UnhideWhenUsed="false" QFormat="true" Name="Intense Emphasis"/>
  <w:LsdException Locked="false" Priority="31" SemiHidden="false"
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   UnhideWhenUsed="false" QFormat="true" Name="Intense Reference"/>
  <w:LsdException Locked="false" Priority="33" SemiHidden="false"
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<![endif]-->

<!--[if gte mso 10]>

 /* Style Definitions */
table.MsoNormalTable
 {mso-style-name:"Table Normal";
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<![endif]-->



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<!--EndFragment-->