Other arrhythmias Part 1
Brugada Syndrome- Funky Faint and a Funky Cove
🩺 Case Scenario
A young, seemingly healthy football player collapses during a weekend game. He is pulseless but receives a successful shock from an on-site AED. In the emergency department, he is alert, afebrile, and hemodynamically stable. There is no history of chest pain, structural heart disease, or drug use. His older brother died suddenly at age 29 while swimming. An ECG is performed, and a strip is shown. See Below
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• Type 1 Brugada: Coved ST elevation ≥2 mm in ≥1 of V1–V3
• Followed by T wave inversion
• Often accentuated with fever or sodium channel blockers
Source: Braunwald’s 2024; UpToDate
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• Fever
• Sodium channel blockers (e.g. flecainide, ajmaline)
• Lithium, tricyclics, alcohol, cocaine
• Hypokalemia or hypercalcemia
Source: Clinical Cardiac Electrophysiology; brugadadrugs.org
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• Loss-of-function mutation in SCN5A
• Affects cardiac sodium channels
• Results in reduced inward Na⁺ current during phase 0
Source: Mayo Clinic Cardiology; Braunwald’s
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• Resuscitated cardiac arrest
• Spontaneous Type 1 ECG + syncope
• Inducible VT/VF on EPS (controversial)
• ICD not routinely recommended for asymptomatic patients without inducibility
Source: UpToDate; Braunwald’s
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• Fever increases Na⁺ channel inactivation
• Can unmask Type 1 Brugada ECG
• Febrile illness may precipitate ventricular arrhythmias
Source: Ferri’s Clinical Advisor; UpToDate
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• Right precordial leads (V1–V2) may need placement in 2nd or 3rd intercostal space
• Increases detection of concealed patterns
• Type 2 and 3 patterns are not diagnostic alone
Source: Clinical Cardiac Electrophysiology
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• Annual risk ~0.5%
• Higher if spontaneous Type 1 ECG
• Syncope or inducibility increases risk significantly
Source: Braunwald’s; UpToDate
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• RBBB
• ARVC (arrhythmogenic RV cardiomyopathy)
• Hyperkalemia
• Pericarditis
Source: Mayo Clinic Cardiology
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• Admit for monitoring
• Aggressive fever control
• Cardiology consult
• Consider unmasking test history or EPS if unclear symptoms
Source: Ferri’s Clinical Advisor; UpToDate
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• Ajmaline, flecainide, or procainamide challenge
• Administered under monitored conditions
• Induces Type 1 ECG if concealed Brugada
• Not used routinely unless diagnosis unclear
Source: Clinical Cardiac Electrophysiology; UpToDate
