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Home > Topics > Cardiac Care
November 03, 2010
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EMS 12-Lead
by Tom Bouthillet

Changing channels: Patient follow-up

Find out what the 12-lead ECG uncovered about the patient

By Tom Bouthillet

-->  Haven't read the initial case presentation? Read: Changing channels

Let's look at the 12-lead ECG again.


This 12-lead ECG shows an abnormality called Brugada syndrome.

This abnormality was first reported in 1992 by the Brugada brothers. In a series of case studies, they showed that ST-elevation in leads V1-V3 with a structurally normal heart was associated with an inherited form of sudden cardiac death.

The AHA/ACCF Scientific Statement on the Evaluation of Syncope (Circulation 2006; 113:316-327) describes the disorder this way:

"The Brugada syndrome is a heritable disorder of the cardiac sodium channel resulting in ST-elevation in the anterior precordial leads (i.e, V1 and V2) and susceptibility to polymorphic ventricular tachycardia. The distinctive ECG pattern is diagnostic, although the ECG is often dynamic...Patients with Brugada syndrome who present with syncope have a 2-year risk of sudden cardiac death of 30%; hence, implantable defibrillator therapy is recommended."

Let's take a closer look at leads V1 and V2 because they are the key to understanding this case.


One of the distinguishing features of Brugada syndrome is the terminal R-wave in leads V1 and V2 that gives Brugada syndrome the general appearance of right bundle branch block.

To get a better idea of what the AHA means by "coved" ST-elevation, let's take a look at another case from a 37-year-old male with syncope.

Credit: Too Old to Work, Too Young to Retire @ tooldtowork.com.

 

This ECG demonstrates how Brugada syndrome can be a STEMI mimic that fools the GE-Marquette 12SL interpretive algorithm (note the ***ACUTE MI SUSPECTED*** message at the top of the ECG).

Let's look at the same patient about 20 minutes later.

Now we can see ST-elevation in leads V1 and V2 that shows the classic "coved" shape most often associated with Brugada syndrome. r.


We also see how the appearance of Brugada syndrome changes over time. You might wonder whether or not it's possible for an acute STEMI to mimic Brugada syndrome. The answer is, "Yes!" If the patient is presenting with classic signs and symptoms of ACS then an ECG like the one above is more likely to be acute STEMI. However, if it's a young patient with syncope it's more likely to be Brugada syndrome.

So what about sudden cardiac arrest with ROSC?

In this case the ECG was suspicious but not diagnostic.

Importantly, the patient's co-workers reported that he seemed "perfectly normal" prior to collapse. This wasn't a patient who had been feeling ill or experiencing chest discomfort.

Further testing revealed clean coronaries and a structurally normal heart.

Brugada syndrome was diagnosed in the EP lab and the patient received an ICD.

He was discharged from the hospital neurologically intact.

See also:
Brugada Syndrome: Report of the Second Consensus Conference (Circulation. 2005;111:659-670.)

About the author


Tom Bouthillet is a Fire Captain/Paramedic with Hilton Head Island Fire & Rescue, Editor of the EMS 12-Lead blog, host of the Code STEMI web series at First Responders Network, a member of the Editoral Advisory Board of EMS World Magazine, and developer of the 12-Lead ECG Challenge smartphone app. He has taught nationally in the Critical Care Transport (CCEMT-P) program out of UMBC and his writings have been referenced in the American Heart Journal, the Journal of the American College of Cardiology: Cardiovascular Interventions and the EP Lab Digest. Contact Tom at tom.bouthillet@ems1.com.
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