Brugada?

[leviathan]

40 y/o Japanese guy c/o daily palpitations has this ECG at rest:
http://imgur.com/uB8utVY,G8HqqbE#0

He's been referred to cards, but any thoughts in the meantime? I see about 1mm STE in V2 and it has a "saddle" appearance, but I'm not convinced it's anything legit. The 2 confirmed cases I've seen were pretty obvious.

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[xaelia]

He's been referred to cards...

...as an inpatient, I hope?

Though, if he made it to age 40, perhaps it's just a mimic.

 

[EMquest3]

Why ignore the obvious STE in V4, V5 and V6 for the saddle shaped STE in V2? I'd say he has STEMI with some pericardial effusion

I don't think those are STE in V4-6, look like large T's to me. Maybe you could say they look a little "peaked."

 

[diphenyl]

Yeah those aren't elevated ST segments those are peaked T waves. That V2 is definitely concerning. It gives the classic saddle back appearance. I would do a thorough family hx. Any family hx of sudden cardiac death? Any previous episodes of syncope? I would repeat this EKG and confirm lead placement. If the V2 looked the same, I'd call it.

 

[glorfindel]

Looks like Brugada to me.

The other thing on the differential would be some sort of rbbb, but I don't see any evidence of that in the lateral leads.

 

[Bostonredsox]

RBBB morphology with a saddle back in V2 and minimal STE in V3. I would call that Brugada.

 

[Rendar5]

Why ignore the obvious STE in V4, V5 and V6 for the saddle shaped STE in V2? I'd say he has STEMI with some pericardial effusion

Kinda hard to call an EKG a STEMI when the only symptoms are palpitations.

 

[bennybrak]

The T waves are peaked but the is still some ST elevation. The STEMI is a long shot cos we don't have the full history. Remember diabetics can get silent MIs

 

[Rendar5]

The T waves are peaked but the is still some ST elevation. The STEMI is a long shot cos we don't have the full history. Remember diabetics can get silent MIs

Silent MI's are not usually truly silent. There's usually some sort of anginal equivalent like nausea, diaphoresis, dyspnea, syncope, jaw or elbow pain. Palpitations is not really what I would consider an equivalent. A STEMI is an EKG+History call, not an EKG call alone. And in this case we do have the history to suggest otherwise. So no, I would not call the cath lab on this one. Yes, I would call the cardiologist and admit the patient to the hospital.

EDIT: in my former ivory tower of residency, I would actually have a cards guy come down to look at the EKG with me to help me interpret it, and maybe even get EP involved. No such luck in the community.

 

[pinipig523]

definitely looks like type 1 brugada... i had a type 2 a couple of weeks ago, it was a lot trickier to see.

EP helped me out and agreed to do the procainamide test.

 

[bougiecric]

with some pericardial effusion

Uh, what?

 

[deleted92121]

I may only be a lowly field medic, but the other day I picked up a 65 y/o F with multiple syncopal episodes over a week. Threw on the 12 lead and I see a funky looking ST segment in V1-V2. Brugada right there in front of me.

Admittedly, many medics have no clue what Brugada is but because of a fantastic cardiology instructor and remembering everything I read, I correctly identified it in the field. Got a kudos from the ED attending (Honestly not bragging but I couldn't help but feel a little proud).

Lady ended up with a lovely ICD and was discharged in reasonably good shape.

Moral of the story: Thanks to all you physicians that take time to educate!

 

[EMquest3]

I may only be a lowly field medic, but the other day I picked up a 65 y/o F with multiple syncopal episodes over a week. Threw on the 12 lead and I see a funky looking ST segment in V1-V2. Brugada right there in front of me.

Admittedly, many medics have no clue what Brugada is but because of a fantastic cardiology instructor and remembering everything I read, I correctly identified it in the field. Got a kudos from the ED attending (Honestly not bragging but I couldn't help but feel a little proud).

Lady ended up with a lovely ICD and was discharged in reasonably good shape.

Morale of the story: Thanks to all you physicians that take time to educate!

How rare is brugada in a 65 y/o?

 

[deleted92121]

How rare is brugada in a 65 y/o?

According to my attending and following up with some research, Brugada in a 65 y/o F who is not of Asian descent is somewhat uncommon. But I was watching a video by Dr. Mattu who mentioned that Brugada is actually more common than once believed and a number of V-fib/V-tach arrests that come in are a result of it. Look up EMRAP Video 65 and it talks about Brugada near the last half of the video.

 

[diphenyl]

I did a research project back on it in med school (back in the day sonny). As my mermory recalls, the most common demographic it was found in was south east asian males. There is frequently a family hx of likely sudden cardiac death. There was a remarkable co-occurrence with WPW as well.

First time I ever saw it in the flesh was a text book case. It was a 35 YO Vietnamese gentleman. Presented c/o 2 episodes of syncope over the past 2 days. Each episode lasted approx 1-2 min's. No preceding or proceeding episodes of CP or SOB. No other neurologic sx's. Family hx was pertinent for father who died suddenly at age 40 for no clear reason. Got the first EKG and it was kind of equivocal for Brugada like findings. Had a witnessed episode of syncope in the ED w/ a couple runs of Vtach. Got follow up EKG right away with text book saddleback ST segments in V2-V3. Called cardiology and got an implantable that afternoon.

 

[WilcoWorld]

leviathan - any follow up on the case?

 

[deleted92121]

I did a research project back on it in med school (back in the day sonny). As my mermory recalls, the most common demographic it was found in was south east asian males. There is frequently a family hx of likely sudden cardiac death. There was a remarkable co-occurrence with WPW as well.

First time I ever saw it in the flesh was a text book case. It was a 35 YO Vietnamese gentleman. Presented c/o 2 episodes of syncope over the past 2 days. Each episode lasted approx 1-2 min's. No preceding or proceeding episodes of CP or SOB. No other neurologic sx's. Family hx was pertinent for father who died suddenly at age 40 for no clear reason. Got the first EKG and it was kind of equivocal for Brugada like findings. Had a witnessed episode of syncope in the ED w/ a couple runs of Vtach. Got follow up EKG right away with text book saddleback ST segments in V2-V3. Called cardiology and got an implantable that afternoon.

I know V1-V2 are the predominant location to identify Brugada but was unaware of any other leads showing the ST changes. Thanks for the info, I'll be sure to keep my eyes open.

 

[leviathan]

leviathan - any follow up on the case?

Last I heard, cardiology refused to see the patient until he had both an echo and holter done. I don't know if they saw the ECG before saying this, or if they saw it and either weren't worried about Brugada or aren't aware of it. I have to hope by 2013 there aren't any cardiologists who aren't familiar with the syndrome.

BTW, no history of sudden death in the family. He is having daily attacks of palpitations w/o any syncopal episodes, but he is feeling light-headed when they happen.

 

[leviathan]

So it gets a little more complicated, but this guy is an international patient and his insurance comapny would only pay for 2/3 of: stress test, holter, and echo. The patient not knowing any better went with the echo (normal) and the stress test. The stress was actually abnormal, he had worsening RBBB and hypotension on the stress test. An on-call cardiologist was re-consulted, who said that the pt. should just go back to Japan immediately to get a more detailed EP workup.