The Case: 72-year-old woman who presents with chest pain.
Rate?
Rhythm?
Axis?
Intervals?
QRST?
Interpretation: Sinus tachycardia HR 112, mild left axis deviation, normal PR interval, pseudo-RBBB morphology, STE in V1-V3 with concave T wave inversions
Discussion: This patient’s ECG is concerning for Brugada syndrome. Brugada syndrome is an inherited sodium channelopathy that most commonly affects men of East and Southeast Asian descent. It is caused by mutations in sodium, potassium, or calcium channels in cardiac myocytes that predispose patients to deadly arrhythmias, namely ventricular tachycardia or ventricular fibrillation. Patients are often diagnosed incidentally on ECG as they are often asymptomatic, although they may present with palpitations, syncope/near syncope, seizures due to cerebral ischemia, or sudden cardiac death. Since the ECG changes may be transient, the underlying arrhythmia can sometimes be unmasked by fever, ischemia, electrolyte disturbances, or ion channel-blocking medications such as flecainide, propafenone, or CCBs.
To diagnose Brugada syndrome, there must be both ECG findings and a corresponding clinical or family history (documented VF or VT, family history of sudden cardiac death age <45, syncope, nocturnal agonal respirations).
Take Home Points:
● Brugada syndrome is an inherited channelopathy affecting ion channels in cardiac myocytes that predisposes patients to VT or VF
● Diagnosis is based on characteristic ECG findings of coved STE in V1-2 with T-wave inversions and ECG
● Admit for cardiology evaluation and AICD placement
Authored by Vladimir Bernstein, MD
Resources:
Larkin J and Buttner R. Brugada Syndrome [Internet]. Life in the Fast Lane • LITFL. 2021 [cited 2024 Jan 4];Available from: https://litfl.com/brugada-syndrome-ecg-library/
Ornato J.P. (2020). Sudden cardiac death. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353§ionid=204498507