EKG Rounds
Elizabeth Haney
17 August 2006
Case
26 yo Caucasian male presents to your ED with hx of a single syncopal episode.
Witnessed, <1minute, no Seizure activity, alert following event.
T 37.3/ HR 80reg/ BP 124/76/ RR 12 O2sat 99%RA/ BG 6.2 Asymptomatic in ED, wants to go home!
What else would you like to know?
Additional History
Assoc. with brief episode of palpitations prior to syncope
No SOB, Chest Pain, N/V, HA PMHx: healthy Meds: nil No street drug use FHx: No known CAD/stroke/seizure/syncope.
Father died in his sleep at 34.
His EKG
Any takers on Dx?
Brugada Syndrome
Twelve-lead surface EKG showing typical pattern of right bundle-branch block and ST-segment elevation of "coved type" in leads V1 to V3 in a patient identified after a syncopal episode
Brugada Syndrome
First described in 1992 by Pedro and Josep Brugada
New syndrome: assoc. w/ SCD in pts w/ structurally normal hearts & no evidence of CAD
Pts had a distinct set of EKG abnormalities:-RBBB pattern, and persistent ST-segment
elevation in the right precordial leads (V1-3).
Epidemiology
Prevalence ranges vary: 0.7-1.0% in Japanese studies, 0.6% in Finnish study, 0.4% in US study.
Male:Female ratio up to 9:1. More common in Asian populations.
Up To Date
Genetics
Autosomal Dominant inheritance 15% to 30% of patients with the Brugada
syndrome, mutations have been found in SCN5A, the cardiac sodium channel α-subunit gene located on chromosome 3
Structural Abnormalities
BS not usually assoc. w/ structural heart dz Evidence supporting subtle microscopic
abnormalities incl. localized myocarditis or microaneurysms. Frustaci et al., Cardiac histological substrate in patients with clinical phenotype of Brugada Sundrome. Circ. 2005 Dec 13;112(24):3680-7.
18 pts in study, 14 w/ RV myocarditis, 7 w/ RV microaneurysms
3 Patterns of ST Elevation
Type 1: elevated ST segment ( >2 mm) descends with an upward convexity to an inverted T wave. = "coved type" Brugada pattern.
Type 2 and type 3 patterns have a "saddle back" ST-T wave configuration, with the elevated ST segment descends toward the baseline, then rises again to an upright or biphasic T wave. The ST segment is elevated
1 mm in type 2 and <1 mm in type 3.
Brugada Waves: 3 Types
Z Kardiol 2004; 93:784–790Thanks Dr. Haager
‘Coved’ ST segments w/ T wave inversion
‘Saddleback’ ST segments•Type 2
•Positive or biphasic T wave•1mmSTE
•Type 3•Positive T wave•<1mm STE
Differential Dx
EKG findings alone not diagnostic. DDx:
RV pathology Compression (tumor, hemopericardium) Inferior MI, RV ischemia, Cardiac contusion RBBB, LVH
Arrhythmogenic right ventricular cardiomyopathy Drugs: class IA (procainamide…), IC (propafenone,
flecainide…), cocaine, TCA’s, and more Hyperkalemia, hypercalcemia
Brugada Pattern vs Syndrome
Brugada Pattern = EKG findings without other clinical criteria
Brugada Syndrome = typical EKG findings with other clinical criteria
Clinical Spectrum
Clinical Manifestations
Related to life-threatening ventricular arrhythmias.
SCD occurs in as many as 1/3rd of pts! Arrhythmic events generally occur between
ages of 22-65. More common at night and during sleep,
usually not related to exercise.
Diagnostic Criteria Type I In evolution. “Strongly consider in pts that meet the following criteria”
Type I EKG pattern of type 1 ST segment elevation (coved type) in >1 lead of V1-
V3and 1 of:
Documented VF Self-terminating polymorphic VT Family Hx of SCD <45 Other Family members w/ Brugada ECG pattern EPS inducibility of VT Unexplained syncope suggestive of a tachyarrhythmia Nocturnal agonal respirations
Wilde et al. Eur Heart J 2002;23:1648
Diagnostic Criteria Type 2 + 3 Type 2 or 3
EKG pattern of type 2 or 3 ST segment elevation (saddle-back type) in >1 lead of V1-V3, with conversion to type 1 following challenge w/ a sodium channel blocker
And1 of: Documented VF Self-terminating polymorphic VT Family Hx of SCD <45 Other Family members w/ Brugada ECG pattern EPS inducibility of VT Unexplained syncope suggestive of a tachyarrhythmia Nocturnal agonal respirations
Proposed Work-Up
Treatment
Refer for EP studies ICD placement When provided with an ICD, mortality at 10-
year follow-up has been 0%. Quinidine (sodium channel blocker) research
shows promise. Currently may have role for pts with ICD and frequent discharges (consider amiodarone, quinidine or hydroquinidine). Uptodate.com
Take Home
Be familiar with the EKG manifestations of Brugada syndrome to ensure early diagnosis and prompt referral.
References Zipes: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed. Brugada P, Brugada J: Right bundle branch block, persistent ST segment elevation
and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. J Am Coll Cardiol 1992;20:1391-1396
Littmann et al., Brugada syndrome and “Brugada sign”: Clinical spectrum with a guide for the clinician ,American Heart Journal, 145;768-778
Frustaci et al., Cardiac histological substrate in patients with clinical phenotype of Brugada Sundrome. Circ. 2005 Dec 13;112(24):3680-7.
Wilde et al., Proposed diagnostic criteria for the Brugada syndrome. Eur Heart J 2002; 23:1648
Mattu et al., The Brugada Syndrome, Am J Emerg Med 2003;21:146-151 Uptodate.com J.,R., and P. Brugada, Determinants of Sudden Cardiac Death in Individuals With the
Electrocardiographic Pattern of Brugada Syndrome and No Previous Cardiac Arrest. Circ. Dec. 2003; 108: 3092-3096
Pts w/ ECG diagnostic of Brugada syndrome and no previous cardiac arrest have an 8% risk of SCD during a short-term follow-up period of 2 years.
Lowest-risk group = no syncopal episodes, diagnostic ECG only with drug challenge, and noninducibility during programmed ventricular stimulation (0.5% incidence of events).
Highest-risk group = combo of a previous history of syncope, a spontaneously abnormal ECG, and inducible sustained arrhythmias during programmed ventricular stimulation (27.2% incidence of events).
J.,R., and P. Brugada, Determinants of Sudden Cardiac Death in Individuals With the Electrocardiographic Pattern of Brugada Syndrome and No Previous Cardiac Arrest. Circ. Dec. 2003; 108: 3092-3096