An Interesting ECG Case – Anterior ST Elevation
A patient calls 911 for recurring palpitations and chest discomfort.
· Male, aged 52, Pilipino descent, smoker for 10 years.
· Developed an upper respiratory infection and fever the last 24 hours.
· Last 3 hours feeling palpitations intermittently, lasting 2-3 minutes, since his fever started. This was associated with some tightness and dizziness. No syncope has occurred.
· Blood pressure: 110/70 mmHg, heart rate: 100 bpm, respiratory rate: 18 breaths per minute, Temp. 39.0 C, oxygen saturation: 98% on room air.
· Previously healthy, on no medication.
· His father died unexpectedly during sleep at age 42. The patient has no siblings.
ECG:
SOURCE: https://litfl.com/brugada-syndrome-ecg-library/
Let’s walk through this ECG together:
1. Sinus tachycardia at 100 BPM.
2. QTC 465 msec.
3. ST elevation in V1-2, of 2-3 mm followed by concave, down sloping ST.
4. A terminal negative T wave associated with the ST elevation.
5. There is no clear r' wave V1.
6. ST depression the limb leads and V3-6 of 0.5-1 mm.
This ECG is a pseudo-right bundle branch block and ST-segment elevation in leads V1 to V2. In this patient the ECG was interpreted as Type 1 Brugada pattern. The patient had negative troponins after assessment in the emergency department. He was admitted for further observation and evaluation of possible Brugada Syndrome and need for ICD placement.
Clinical Significance of Brugada Syndrome:
· Brugada Syndrome is a genetic disorder that can cause arrhythmias including atrial fibrillation, life-threatening ventricular tachyarrhythmias and sudden cardiac death.
· Brugada Syndrome is known for its distinctive ECG pattern.
· Classic findings are ST-segment elevation in the right precordial leads (V1-V3) with a "coved" appearance followed by an inverted T-wave, the type 1 Brugada pattern.
· The ECG changes can fluctuate over time and may not always be present, making diagnosis challenging.
· The Brugada Type 2 pattern (not Syndrome) is a variation that may be seen without the same risk of sudden death.
· Brugada Type 2 has >2mm of saddleback shaped ST elevation without a negative T wave.
· Despite the ECG resembling a STEMI, the ST-segment elevation is not typically accompanied by cardiac marker elevation.
· Treatment of Brugada Syndrome often involves implantation of a cardioverter-defibrillator (ICD) to prevent sudden cardiac death.
Brugada Type 2 Pattern:
SOURCE: https://litfl.com/brugada-syndrome-ecg-library/
