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UDK: 612.172.2-053.2
RISK FACTORS IN THE DEVELOPMENT OF EARLY VENTRICULAR
REPOLARIZATION SYNDROME AND ANALYSIS OF PHASE INDICES ON ECG
Efimenko O.V., Kholmatov D.N., Khaidarova L.R.
Andijan State Medical Institute
Republic of Uzbekistan
Relevance.
To date, pediatric arrhythmology still faces many unresolved and pressing issues that
require active attention [6,8]. The growing interest in the problem of rhythm and conduction
disorders of the heart is due to the steady increase in the proportion of arrhythmias within the
structure of cardiological pathology over recent decades. These disorders are often a cause of
death in childhood [1,2].
Experience has shown that the widespread introduction of electrocardiological methods
(especially 24-hour ECG monitoring), ultrasound diagnostics, and other non-invasive and
invasive electrophysiological methods, as well as interventional technologies and advances in
scientific research on the pathophysiological mechanisms of arrhythmias in children—including
studies on autonomic regulation of heart rhythm—has significantly advanced the early diagnosis
of arrhythmias. This, in turn, makes it possible to develop preventive programs for the treatment
and prevention of heart rhythm disorders in children [2,3,7].
The choice of methods and tools for treating rhythm disturbances in childhood remains a major
challenge. It must take into account the multifactorial nature and complex pathophysiological
mechanisms of such disorders. Late diagnosis and inadequate prognosis of arrhythmias are key
contributors to high morbidity and mortality at older ages, and the success of preventive
programs directly depends on their early implementation [1,2,6].
One of the most frequently observed cardiac rhythm disorders is the Early Repolarization
Syndrome (ERS) — an ECG phenomenon whose pathogenesis and clinical significance continue
to attract the attention of practicing physicians. This is due to its high prevalence, as it occurs
both in healthy individuals and in those with heart diseases, while its clinical implications remain
uncertain. It is assumed that ERS is based on congenital individual features of the
electrophysiological processes in myocardial cells, including ion mechanisms that lead to early
repolarization of the subepicardial layers of the myocardium [4,5].
According to studies by other authors, the development of ERS involves enhanced
parasympathetic influence on heart rhythm, increased sympathetic activity in the area of the
interventricular septum and the anterior wall of the left ventricle; the activity of accessory
conduction pathways; and disturbances in electrophysiological processes within myocardial cells,
leading to impaired potassium current across the cell membrane in the apex and lateral wall of
the left ventricle [1,3,8].
Objective of the study:
To identify risk factors involved in the development of Early
Repolarization Syndrome (ERS) and to present and analyze the phase parameters of electrical
systole based on ECG data.
Materials and methods.
A population-based approach was used in the selection and analysis of
material to identify schoolchildren with various types of cardiac rhythm and conduction
disorders.
For each child, a specially designed questionnaire was completed, including anamnesis data and
findings from objective examination, along with anthropometric measurements (height, weight,
circumferential dimensions with calculation of index parameters).
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All children underwent electrocardiography according to the standard 12-lead method. Interval
and phase parameters were calculated, including electrical diastole, the duration of electrical
activity and cardiac stability, as well as their ratios. In addition, the amplitude values of the
ventricular complex were determined.
Results.
Out of a total of 562 ECG examinations conducted among schoolchildren aged 7 to 14,
Early Repolarization Syndrome (ERS) was identified in only 22 children among the various
types of rhythm and conduction disorders. The diagnostic criterion for this rhythm abnormality
was an elevation of the ST-T segment above the isoelectric line, beginning from an elevated
junction point (J-point) on the descending limb of the R wave or from a J-wave.
In our study, the frequency of this syndrome decreased with age among girls (from 1,21% to
0,72%), while it increased among boys (from 0,43% to 1,59%, p < 0,01).
Anamnesis revealed that all children with ERS had a history of pathological pregnancy and
delivery in their mothers. It is evident that the development of the cardiovascular system,
including the cardiac conduction system during the postnatal period, is significantly influenced
by the course of the intranatal period — specifically, complications during pregnancy and
childbirth (such as late gestosis, threatened miscarriage, weak labor activity, intrauterine fetal
hypoxia, placental and umbilical cord pathologies, obstetric interventions during delivery, and
neonatal asphyxia).
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All these risk factors apparently had a certain impact on the development of an imbalance in the
functioning of the sympathetic and parasympathetic nervous systems.
In addition, all children with ERS were found to have a high incidence of background pathology
at early ages (36.3%), droplet-transmitted infections (22,7%), and upper respiratory tract
infections of viral and bacterial origin (81,8%). A notably high proportion of these children had
chronic foci of infection (90,9%).
The complaints reported by children with ERS were predominantly of autonomic nature—
restlessness, irritability, sudden mood swings, various sleep disturbances (delayed sleep onset,
difficulty waking up, night terrors), palmar hyperhidrosis, headaches and dizziness, as well as
decreased attention span.
Table 1. Complaints of children with early ventricular repolarization syndrome
.
Complaint
аbs
%
Anxiety
20
90,9%
Irritability
18
81,8%
Sharp mood swings
22
100%
Late falling asleep
6
27,3%
Difficulty waking up
9
40,9%
Night terrors
4
18,2%
Hyperhidrosis
19
86,4%
Headaches and dizziness
22
100%
Decreased attention
12
54,5%
When assessing physical status, the children were divided into two age groups: 7–10 years and
11–14 years.
Analysis of calculated indicators in the 7–10-year age group revealed no significant changes in
the main anthropometric parameters. However, in children with ERS, an increase in Erisman and
Pignet indices was observed.
This suggests that children with ERS have disproportionate chest circumference development
relative to their div weight and height.
In the 11–14-year-old group, the analysis of physical development parameters in children with
ERS showed increased height and decreased div mass, as well as high values for div surface
area and the "asthenic" index. These findings indicate that children with ERS in this age group
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tend to have a dolichomorphic growth pattern—that is, a predominance of longitudinal growth.
This was confirmed by low values of the Varga index (as increased height lowered the calculated
Varga index) and high values of the "asthenia" index.
Further examination of children with ERS included an analysis of interval and phase parameters
based on ECG data. Given that Early Repolarization Syndrome remains poorly understood in
pediatric pathogenesis and that its ECG criteria are still not fully established, we analyzed
several additional ECG parameters beyond those commonly described in the literature.
We found that in children with Early Repolarization Syndrome (ERS), there is a shortening of
the cardiac cycle (RR interval, sec) (0.64±0.02) and an increased heart rate compared to
normative values for healthy children of the same age.
In children with ERS, there was a significant shortening of the P-Q interval (0,10±0,002), the
actual QRST phase duration (QRSTa, sec) (0,320±0,004), the expected QRST duration (QRSTd,
sec) (0,312±0,003), and R-wave peak time in lead V1, sec (0,02±0,001), as well as shortening of
the QRS segment (0,07±0,001) and rightward deviation of the electrical axis of the heart (EAX).
When examining the duration of electrical activity (P-T), cardiac stability (T-R), and electrical
diastole (T-Q), a more pronounced shortening of the P-T interval compared to the T-P interval
was noted, along with a significant reduction in the T-Q interval.
Thus, a distinguishing feature of Early Repolarization Syndrome (ERS) is that certain ECG
segments should be attributed to the repolarization phase. In this regard, we studied the structure
of repolarization on the ECG: the "excitation phase" of the ventricles (Q–T
1
) and the
"termination phase of excitation" in the ventricles (T
1
–T). The analysis revealed a shortening of
the Q-T
I
and ST–T intervals, while the final part of repolarization, i.e., the T
I
-Т interval,
remained unchanged.
At the same time, the ratios of Q–T and ST–T to the total electrical systole (QT
I
/QT
I
% and ST-
T/QT
I
%) were reduced, whereas the T
I
–T/Q–T
I
ratio was increased. This trend was also
observed in the ratios of Q–T
I
and ST–T to the entire cardiac cycle. However, the share of the
T
I
–T segment within the total cardiac cycle remained unchanged.
Thus, in children with ERS, the Q–T
I
ECG parameter—which includes the depolarization phase
(QRS) and the early phase of repolarization (ST–T)—was shortened. This led to a decrease in
QT
I
values both within the structure of electrical systole (QT
I
/QT%) and throughout the cardiac
cycle (Q–T
I
/RR%). The resulting electrophysiological situation suggests that repolarization
begins earlier, due to shortening of the QRS complex and the early part of the repolarization
phase (ST–T), while the T
I
–T segment, representing the late repolarization phase, is prolonged.
Since early ventricular repolarization precedes the shortening of atrioventricular conduction (P–
Q interval) and the QRS complex, we propose that ERS should be regarded as a variant of the
ventricular pre-excitation syndrome. Premature ventricular depolarization facilitates early onset
of repolarization. This origin of ERS is likely related to the postnatal functioning of an accessory
atriofascicular Mahaim–Levy fiber, which conducts impulses from the atria—most often to the
anterosuperior branch of the left bundle of His—causing segmental, premature, asynchronous
ventricular excitation.
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