An Interesting ECG Case

52-year-old male of Filipino descent, smoker, presenting with 3 hours of palpitations, chest tightness, and dizziness. There are no complaints of syncope. He is currently febrile: T = 39.0°C, vital signs otherwise normal. For the past 3 days, he has had a cough, sore throat, and felt generally unwell.
His father died suddenly in sleep at age 42. He has no siblings. EMS does this ECG:

Is he having a STEMI?

No, this ECG shows:

·      normal sinus rhythm

·      nonspecific diffuse ST T abnormalities in the limb leads

·      RSR′-like morphology in V1 mimicking RBBB, but without true conduction delay (QRS < 120 ms)

·      Absence of wide terminal S waves in lateral leads (e.g., I, V6) differentiating it from true RBBB

·      "Coved" ST-segment elevation in V1–V2

·      The elevated ST segment has a gradual down sloping shape, followed by a deeply inverted T wave

These findings are typical of the Brugada Type 1 pattern.

Clinical Significance of Brugada Syndrome:

• Genetic disorder involving mutations in cardiac sodium channels (e.g., SCN5A)

• Predominantly affects males of Southeast Asian descent

• Risk of sudden cardiac death due to polymorphic ventricular tachycardia or ventricular fibrillation

• Can be unmasked or worsened by:

• Fever

• Sodium channel blockers (e.g., procainamide, flecainide)

• Certain antidepressants, anesthetics, or alcohol

Management:

• Asymptomatic patients may not require intervention. These patient should be assessed by a Cardiologist to make a management plan.

• Implantable cardioverter-defibrillator (ICD) is recommended for patients with syncope or documented ventricular arrhythmia

• Avoidance of triggers, especially drugs and fever, is essential