Thursday, 18 July 2013

Brugada 'Editorial' by Dr Ken Grauer

Guest 'Editorial' by Dr Ken Grauer author of ECG Interpretation Blog

Dr Grauer posted an extensive 'editorial' comment on our ECG case from this week, a young patient with Type 1 Brugada, syncope, and recurrent epsiodes of VF.
To avoid people missing this comment I've created this special 'Editorial' post.

Excellent case by John Larkin - with a classic ECG pattern plus bonus of not only displaying Brugada Type 1 changes in leads V1,V2 - but also J-point subtle-but-real ST elevation in leads I,aVL - legitimate ST elevation in lead V3 (that does not look like the Brugada changes we see in V1,V2) - a "telltale" PVC (this patient had several VF episodes soon thereafter) - plus almost hyperacute (broad) T waves in several leads and a hint of lateral precordial ST depression. Certainly not normal accompaniments to the ominous pattern we see in leads V1,V2.

Words don't do the "Brugada Type I ST Segment" justice. More than just "cove-shaped ST elevation ≥2mm with negative T in ≥1 leads V1-3" - You just have to see (and embed) the picture of the ST segments of Brugada Syndrome in your mind. It is not RBBB or incomplete RBBB. The ST segment elevation doesn't last; instead there is a rapid downslope (steeply directed downward) that is not Wellens, and unique to Brugada syndrome. A picture is worth a thousand words. The image in V1,V2 of this case needs to be embedded in the mind.

As to "rarity" of the syndrome - there is to me a "disconnect". How can what is now felt to be one of the most common causes of sudden death in younger adults be "rare"? It IS "out there". It is not commonly out there in classic ECG form as in the classic tracing of this case obtained from a man with syncope and then VFib in the ED. But Brugada Syndrome seems to be far more prevalent than it ever was in years past - and the pattern WILL be seen by virtually all medical providers who obtain and interpret ECGs on their patients.

But the concern is not so much with classic cases as the one presented here - in which the need for immediate referral to Cardiology for AICD placement after resuscitation from VFib is obvious. Instead - the much more prevalent issue is what to do with all the not-quite-Brugada-pattern ECGs that show saddleback (rather than downsloping) ST segment elevation in anterior leads - or perhaps hint of more than a simple rSr' in V1 with high J-point takeoff - and in addition present with a history of perhaps questionable presyncope - equivocal family history of sudden death - and/or perhaps manifest background "benign" early repolarization on 12-lead (that might not be so "benign" ). "Rarity" is a relative term. We are increasingly appreciating the legion of other conditions that may intermittently precipitate Brugada-like ECG manifestations - including fever, various drugs, stress, hot baths, hypokalemia, other severe medical illness. What clinical implications are for these intermittent Brugada-like patterns is far less certain. Almost wishing you didn't see such patterns - the question then arises as to what truly merits not only referral, but consideration for prophylactic AICD placement? Not all answers are in - but we'll all be watching as management of this entity refines over the near future. In the meantime - awareness of frank cases such as the illustrative one presented here need to be universally recognized on sight for the ominous threat they pose by all health care providers.

THANKS for presenting this great case John!

Dr Ken Grauer, MD
KG/EKG Press, Professor Emeritus in Family Medicine
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I'd like to thank Dr Ken Grauer for his ongoing support and contribution to our blog.