Brugada ECG Sign & Chest Pain Mimicking ST Elevation Myocardial Infarction
Background: Management of patients with the brugada ECG sign who have no previous history of syncope is still negotiable. We present a case of a 57 year-old Caucasian lady who presented to the emergency department with substernal chest pain. Results: Her past medical history showed that she had two previous episodes of lightheadedness, but no syncope. She had a family history of sudden death secondary to unknown cause in her aunt at the age of 61. Physical exam was unremarkable except for diaphoresis. Electrocardiography (ECG) showed ST elevation in the right precordial leads (V1-V2) with T inversion, mimicking a STEMI. Emergent cardiac catheterization revealed normal coronary arteries. Echocardiogram was normal. Again, interpretation of ECG revealed a Brugada type 1 pattern, characterized by coved-type, gradually descending ST-T segment, elevated J point of more than 2 mm and T wave inversion. Electrophysiological (EPS) testing with a Sodium channel blocker challenge showed a persistent Brugada type 1 pattern with non-inducible ventricular tachycardia. This patient had Brugada type 1 ECG pattern with no previous history of syncope (asymptomatic). Thus she was considered at low risk of developing a serious arrhythmogenic event in the future. Conclusion: A history of syncope remains the best available predictor for arrhythmogenic events. EPS testing in such patients, to stratify the risk and predict for any future events, is still controversial. It is still unjustified to place an implantable cardioverter-defibrillator in asymptomatic non-inducible individuals with the Brugada pattern. These patients should follow up closely with a cardiologist and be aware of the risk of possible triggers of ventricular arrhythmias.
2. Brugada P, Brugada J. Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. A multicenter report. J Am Coll Cardiol 1992; 20(6):1391-6.
3. Scherr D, Brunner G, Kaufmann P, et al. Aborted sudden death in a patient with a structurally normal heart: the Brugada syndrome. Intensive Care Med 2002;28(6):789–92.
4. Atarashi H, Ogawa S, Harumi K, et al. Characteristics of patients with right bundle branch block and ST-segment elevation in right precordial leads. Idiopathic Ventricular Fibrillation Investigators. Am J Cardiol 1996;78(5):581-3.
5. Brugada J, Brugada P. What to do in patients with no structural heart disease and sudden arrhythmic death? Am J Cardiol 1996;78(5A):69-75
6. Alings M, Wilde A. “Brugada” syndrome: clinical data and suggested pathophysiological mechanism. Circulation 1999;99(5):666-73. 7. Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008; 117(21):e350-480.
8. Wilde AA, Antzelevitch C, Borggrefe M, et al. Proposed diagnostic criteria for the Brugada syndrome. Eur Heart J 2002;23(21):1648-54.
9. Littmann L, Monroe MH, Kerns WP, Svenson RH, Gallagher JJ. Brugada syndrome and “Brugada sign”: clinical spectrum with a guide for the clinician. Am Heart J 2003;145(5):768–78.
10. Probst V, Veltmann C, Eckardt L, et al. Long-term prognosis of patients diagnosed with Brugada syndrome. Results from the FINGER Brugada Syndrome Registry. Circulation 2010;121(5):635-43.
11. Priori SG, Napolitano C, Gasparini M, et al. Clinical and genetic heterogeneity of right bundle branch block and ST-segment elevation syndrome: A prospective evaluation of 52 families. Circulation 2000;102(20):2509-15.
12. Takenaka S, Kusano KF, Hisamatsu K, et al. Relatively benign clinical course in asymptomatic patients with Brugada-type electrocardiogram without family history of sudden death. J Cardiovasc Electrophysiol 2001;12(1):2–6
13. Miyasaka Y, Tsuji H, Yamada K, et al. Prevalence and mortality of the Brugada-type electrocardiogram in one city in Japan. J Am Coll Cardiol 2001;38(3):771-4.
14. Atarashi H, Ogawa S, Harumi K, et al. Three-year follow-up of patients with right bundle branch block and ST segment elevation in the right precordial leads: Japanese Registry of Brugada Syndrome. Idiopathic Ventricular Fibrillation Investigators. J Am Coll Cardiol 2001;37(7):1916-20.
15. Priori SG, Napolitano C, Gasparini M, et al. Natural history of Brugada syndrome: insights for risk stratification and management. Circulation 2002;105(11):1342-7.
16. Brugada J, Brugada R, Antzelevitch C, et al. Long-term follow-up of individuals with the electrocardiographic pattern of right bundle-branch block and ST-segment elevation in precordial leads V1 to V3. Circulation 2002;105(1):73-8.
17. Eckardt L, Probst V, Smits JP, et al. Long-term prognosis of individuals with right precordial ST-segment-elevation Brugada syndrome. Circulation 2005;111(3):257-63.
18. Matsuo K, Akahoshi M, Nakashima E, et al. Clinical characteristics of subjects with the Brugada-type electrocardiogram. J Cardiovasc Electrophysiol 2004;15(6):653-7.
19. Matsuo K, Akahoshi M, Nakashima E, et al. The prevalence, incidence and prognostic value of the Brugada-type electrocardiogram: a population-based study of four decades. J Am Coll Cardiol 2001;38(3):765-70.
20. Junttila MJ, Raatikainen MJ, Karjalainen J, et al. Prevalence and prognosis of subjects with Brugada-type ECG pattern in a young and middle-aged Finnish population. Eur Heart J 2004;25(10):874-8.
21. Monroe MH, Littmann L. Two-year case collection of the Brugada syndrome electrocardiogram pattern at a large teaching hospital. Clin Cardiol 2000;23(11):849-51.
22. Di Diego JM, Cordeiro JM, Goodrow RJ, et al. Ionic and cellular basis for the predominance of the Brugada syndrome phenotype in males. Circulation 2002;106(15):2004-11.
23. Antzelevitch C, Brugada P, Borggrefe M, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation 2005;111(5):659-70.
24. Chen Q, Kirsch GE, Zhang D, et al. Genetic basis and molecular mechanism for idiopathic ventricular fibrillation. Nature 1998;392(6673):293-6.
25. Gehi AK, Duong TD, Metz LD, Gomes JA, Mehta D. Risk stratification of individuals with the brugada electrocardiogram: A meta-analysis. J Cardiovasc Electrophysiol 2006;17(6):577-83.
26. Gussak I, Antzelevitch C, Bjerregaard P, et al. The Brugada syndrome: clinical, electrophysiologic and genetic aspects. J Am Coll Cardiol 1999;33(1):5-15.
27. Amin AS, Meregalli PG, Bardai A, Wilde AA, Tan HL. Fever increases the risk for cardiac arrest in the Brugada syndrome. Ann Intern Med 2008;149(3):216-8.
28. Rouleau F, Asfar P, Boulet S, et al. Transient ST segment elevation in right precordial leads induced by psychotropic drugs: relationship to the Brugada syndrome. J Cardiovasc Electrophysiol 2001;12(1):61-5.
29. Goldgran-Toledano D, Sideris G, Kevorkian JP. Overdose of cyclic antidepressants and the Brugada syndrome. N Engl J Med 2002;346(20):1591-2.
30. Brugada J, Brugada R, Brugada P. Determinants of sudden cardiac death in individuals with the electrocardiographic pattern of Brugada syndrome and no previous cardiac arrest. Circulation 2003;108(25):3092-6.
31. Ikeda T. Brugada syndrome: current clinical aspects and risk stratification. Ann Noninvasive Electrocardiol 2002;7(3):251–62.
32. Priori SG, Gasparini M, Napolitano C, et al. Risk stratification in Brugada syndrome: results of the PRELUDE (PRogrammed ELectrical stimUlation preDictive valuE) registry. J Am Coll Cardiol 2012;59(1):37-45.
33. Paul M, Gerss J, Schulze-Bahr E, et al. Role of programmed ventricular stimulation in patients with Brugada Syndrome: a meta- analysis of worldwide published data. Eur Heart J 2007;28(17):2126-33.
34. Gussak I, Bjerregaard P, Hammill SC. Clinical diagnosis and risk stratification in patients with Brugada syndrome. J Am Coll Cardiol 2001;37(6):1635–8.
35. Takenaka S, Emori T, Koyama S, et al. Asymptomatic form of Brugada syndrome. Pacing Clin Electrophysiol 1999;22(8):1261–3.
36. Brugada P. Brugada syndrome: an electrocardiographic diagnosis not to be missed. Heart 2000;84(1):1–2
37. Brugada P, Brugada R, Brugada J, Geelen P. Use of the prophylactic implantable cardioverter defibrillator for patients with normal hearts. Am J Cardiol 1999;83(5B):98D–100D
38. Brugada P, Brugada R, Brugada J. Should patients with an asymptomatic Brugada electrocardiogram undergo pharmacological and electrophysiological testing? Circulation 2005;112(2):279-92.
39. Priori SG, Napolitano C. Should patients with an asymptomatic Brugada electrocardiogram undergo pharmacological and electrophysiological testing? Circulation 2005;112(2):279-92.
40. Belhassen B, Glick A, Viskin S. Efficacy of quinidine in high-risk patients with Brugada syndrome. Circulation 2004;110(13):1731-7.
41. Belhassen B, Viskin S, Fish R, Glick A, Setbon I, Eldar M. Effects of electrophysiologic-guided therapy with Class IA antiarrhythmic drugs on the long-term outcome of patients with idiopathic ventricular fibrillation with or without the Brugada syndrome. J Cardiovasc Electrophysiol 1999;10(10):1301- 12.
42. Viskin S, Wilde AA, Tan HL, Antzelevitch C, Shimizu W, BelhassenB. Empiric quinidine therapy for asymptomatic Brugada syndrome: Time for a prospective registry. Heart Rhythm 2009;6(3):401-4.
43. Rosso R, Glick A, Glikson M, et al. Outcome after implantation of ICD in patients with Brugada syndrome: a multicenter Israeli study (ISRABRU) Isr Med Assoc J 2008;10(6):435–9.
44. Brugada J, Brugada R, Brugada P. Right bundle-branch block and ST-segment elevation in leads V1 through V3: a marker for sudden death in patients without demonstrable structural heart disease. Circulation 1998;97(5):457-60.
45. Sacher F, Probst V, Iesaka Y, et al. Outcome after implantation of a cardioverter-defibrillator in patients with Brugada syndrome: a multicenter study. Circulation 2006;114(22):2317-24.
46. Sarkozy A, Boussy T, Kourgiannides G, et al. Long-term follow-up of primary prophylactic implantable cardioverter-defibrillator therapy in Brugada syndrome. Eur Heart J 2007;28(3):334-44.
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