Brugada syndrome: Difference between revisions
(Text replacement - "*ECG" to "*ECG") |
Elcatracho (talk | contribs) (/* ECG Unmasking FactorsIkeda T., Abe A., Yusu S.; The full stomach test as a novel diagnostic technique for identifying patients at risk of Brugada syndrome. J Cardiovasc Electrophysiol. 17 2006:602-607.Shimeno K., Takagi M., Maeda K., Tatsumi...) |
||
(30 intermediate revisions by 6 users not shown) | |||
Line 5: | Line 5: | ||
*Much more common in men (up to 9x), particularly Southeast Asian males | *Much more common in men (up to 9x), particularly Southeast Asian males | ||
*[[ECG]] shows incomplete [[RBBB]] with [[ST elevation]] in V1-V3 | *[[ECG]] shows incomplete [[RBBB]] with [[ST elevation]] in V1-V3 | ||
**In uncomplicated RBBB, usually there no ST change to slight ST depression | **In uncomplicated RBBB, usually there is no ST change to slight ST depression | ||
**If presenting symptom is chest pain rather than syncope, consider strongly STEMI | **If presenting symptom is chest pain rather than syncope, consider strongly STEMI | ||
==Clinical Features== | ==Clinical Features== | ||
*Typically asymptomatic | *Typically asymptomatic | ||
*Patients may have Vfib arrest or sudden death | *Patients may have [[Vfib]] [[cardiac arrest]] or sudden death | ||
*Diagnostic ECG findings transient and variable, with only 1/3 of serial ECGs diagnostic in confirmed spontaneous coved-type Brugada syndrome | *Diagnostic [[ECG]] findings transient and variable, with only 1/3 of serial ECGs diagnostic in confirmed spontaneous coved-type Brugada syndrome patients<ref>Richter S., Sarkozy A., Veltmann C.; Variability of the diagnostic ECG pattern in an ICD patient population with Brugada syndrome. J Cardiovasc Electrophysiol. 20 2009:69-75.</ref> | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Line 18: | Line 18: | ||
==Evaluation== | ==Evaluation== | ||
===ECG Criteria=== | ===ECG Criteria=== | ||
[[File:Brugada.jpg|thumb|600px|Brugada ECG findings by type.]] | |||
*Type 1 | |||
**Elevated ST segment (>2mm) | |||
**Descends with upward convexity to a TWI | |||
*Type 2 | |||
**Elevated ST segment (>1mm) | |||
**Descends toward baseline then rises again (saddleback) to upright T wave | |||
*Type 3 | |||
**Elevated ST segment (<1mm) | |||
**Descends toward baseline then rises again to upright T wave | |||
''v1-v2 lead placement in 2nd or 3rd IC spaces (rather than conventional 4th IC space) increases chance of recording type I pattern<ref>Shimizu W., Matsuo K., Takagi M.; Body surface distribution and response to drugs of ST segment elevation in Brugada syndrome: clinical implication of eighty-seven-lead body surface potential mapping and its application to twelve-lead electrocardiograms. J Cardiovasc Electrophysiol. 11 2000:396-404.</ref>'' | |||
====ECG Unmasking Factors<ref>Ikeda T., Abe A., Yusu S.; The full stomach test as a novel diagnostic technique for identifying patients at risk of Brugada syndrome. J Cardiovasc Electrophysiol. 17 2006:602-607.</ref><ref>Shimeno K., Takagi M., Maeda K., Tatsumi H., Doi A., Yoshiyama M.; Usefulness of multichannel Holter ECG recording in the third intercostal space for detecting type 1 Brugada ECG: comparison with repeated 12-lead ECGs. J Cardiovasc Electrophysiol. 20 2009:1026-1031.</ref><ref>Keller D.I., Huang H., Zhao J.; A novel SCN5A mutation, F1344S, identified in a patient with Brugada syndrome and fever-induced ventricular fibrillation. Cardiovasc Res. 70 2006:521-529.</ref><ref>ANTZELEVITCH, C., & BRUGADA, R. (2002). Fever and Brugada Syndrome. Pacing and Clinical Electrophysiology, 25(11), 1537–1539. doi:10.1046/j.1460-9592.2002.01537.x</ref>==== | |||
*Type 1 ECG findings can be transient and "unmasked" by the following: | |||
**[[Fever]] | |||
**Fever | |||
**Night time | **Night time | ||
**After heavy meals | **After heavy meals | ||
**Recovery phase of exercise<ref>Makimoto H., Nakagawa E., Takaki H.; Augmented ST-segment elevation during recovery from exercise predicts cardiac events in patients with Brugada syndrome. J Am Coll Cardiol. 56 2010:1576-1584.</ref> | **Recovery phase of exercise<ref>Makimoto H., Nakagawa E., Takaki H.; Augmented ST-segment elevation during recovery from exercise predicts cardiac events in patients with Brugada syndrome. J Am Coll Cardiol. 56 2010:1576-1584.</ref> | ||
====Higher Risk [[ECG]] Features==== | |||
*[[Early repolarization]] with J-point elevation in inferior leads (seen in 10% of Brugada syndrome)<ref>Sarkozy A., Chierchia G.B., Paparella G.; Inferior and lateral electrocardiographic repolarization abnormalities in Brugada syndrome. Circ Arrhythm Electrophysiol. 2 2009:154-161.</ref> | |||
*QRS widening > 120 ms in V2<ref>Junttila M.J., Brugada P., Hong K.; Differences in 12-lead electrocardiogram between symptomatic and asymptomatic Brugada syndrome patients. J Cardiovasc Electrophysiol. 19 2008:380-383.</ref> | |||
* | *[http://www.ipej.org/1205/morita1.jpeg QRS fragmentation] (additional QRS complex spikes)<ref>Take Y and Morita H. Fragmented QRS: What Is The Meaning? Indian Pacing Electrophysiol J. 2012 Sep-Oct; 12(5): 213–225.</ref><ref>Morita H., Kusano K.F., Miura D.; Fragmented QRS as a marker of conduction abnormality and a predictor of prognosis of Brugada syndrome. Circulation. 118 2008:1697-1704.</ref> | ||
[[ | *[[ST elevation]] during recovery after exercise | ||
===Diagnosis=== | |||
*Diagnosed when a patient has Burdada's ECG pattern (see above) AND documented ventricular tachydysrhythia or history consistent with ventricular tachydysrythmia (e.g. [[syncope]], sudden cardiac death)<ref>M Sharon, et al. ECG of the Month. Annals of Emergency Medicine. December 2019. 74(6);782-785</ref> | |||
==Management== | ==Management== | ||
*Cardiology consultation | ''Acute ED management depends on presenting symptoms'' | ||
===Incidental Brugada Pattern on ECG (Otherwise Asymptomatic)=== | |||
*No acute treatment | |||
===Concerning Cardiac Symptoms=== | |||
*Cardiology consultation and likely admission | |||
**Consider EP consult and VF-inducing electrophysiologic study (EPS), though EPS is controversial prognosticator<ref>Viskin S and Rosso R. Risk of Sudden Death in Asymptomatic Brugada Syndrome: Not as High as We Thought and Not as Low as We Wished…But the Contrary. J Am Coll Cardiol. 2010;56(19):1585-1588.</ref> | |||
===Active Tachydysrhythmia=== | |||
*Antidysrhythmics trials have inconsistently shown clinical benefit, but potential VF-terminating and prevention meds may include [[quinidine]], [[isoproterenol]]<ref>Postema PG, Wolpert C, Amin AS, Probst V, Borggrefe M, Roden DM, et al. Drugs and Brugada syndrome patients: review of the literature, recommendations, and an up-to-date website (www.brugadadrugs.org). Heart Rhythm. 2009 Sep. 6(9):1335-41.</ref> | |||
*See [[electrical storm]] for 3 or more episodes of sustained [[ventricular tachycardia]], [[ventricular fibrilation]], or ICD shocks within 24 hours | |||
===Drugs to be Avoided=== | |||
*If starting or using new med, check [http://www.brugadadrugs.org/drug-lists/ www.brugadadrugs.org drug list] | |||
*Commonly used meds to avoid include: | |||
**[[Procainamide]] | |||
**[[Bupivacaine]] | |||
**[[Propofol]] | |||
**[[Ketamine]] | |||
**[[Tramadol]] | |||
**[[Lithium]] | |||
**Except for quinidine, class I antiarrhythmic drugs, particularly sodium channel blockers such as procainamide and flecainide should be avoided | |||
**Certain [[antiepileptics|antiepileptic]] medications | |||
**Certain [[tricyclic antidepressants]] | |||
**Certain [[SSRIs]] | |||
==Disposition== | ==Disposition== | ||
* | *Incidental finding with no suggestive family or patient history (e.g. syncope, tachydysrhythmia, sudden cardiac death)--> education and general cardiology referral<ref>M Sharon, et al. ECG of the Month. Annals of Emergency Medicine. December 2019. 74(6);782-785</ref> | ||
*Suggestive family or patient history --> disposition in consultation with cardiology<ref>M Sharon, et al. ECG of the Month. Annals of Emergency Medicine. December 2019. 74(6);782-785</ref> | |||
*Active tachydysrhythmia --> admission<ref>M Sharon, et al. ECG of the Month. Annals of Emergency Medicine. December 2019. 74(6);782-785</ref> | |||
===Inpatient vs Outpatient ICD Placement=== | |||
*Prophylactic ICDs may have risks of complications greater than benefits conferred<ref>Sacher F., Probst V., Iesaka Y.; Outcome after implantation of a cardioverter-defibrillator in patients with Brugada syndrome: a multicenter study. Circulation. 114 2006:2317-2324.</ref><ref>Rosso R., Glick A., Glikson M.; Outcome after implantation of cardioverter defibrillator in patients with Brugada syndrome: a multicenter Israeli study (ISRABRU). Isr Med Assoc J. 10 2008:435-439.</ref> | |||
==External Links== | ==External Links== |
Revision as of 18:02, 1 January 2021
Background
- Consider as cause of syncope in patients with family history of sudden death
- 80% of Brugada syndrome diagnosed only after a cardiac arrest[1]
- Autosomal dominant Na-channelopathy which increases the risk of sudden cardiac death (~10%/yr)[2]
- Much more common in men (up to 9x), particularly Southeast Asian males
- ECG shows incomplete RBBB with ST elevation in V1-V3
- In uncomplicated RBBB, usually there is no ST change to slight ST depression
- If presenting symptom is chest pain rather than syncope, consider strongly STEMI
Clinical Features
- Typically asymptomatic
- Patients may have Vfib cardiac arrest or sudden death
- Diagnostic ECG findings transient and variable, with only 1/3 of serial ECGs diagnostic in confirmed spontaneous coved-type Brugada syndrome patients[3]
Differential Diagnosis
ST Elevation
- Cardiac
- ST-segment elevation myocardial infarction (STEMI)
- Post-MI (ventricular aneurysm pattern)
- Previous MI with recurrent ischemia in same area
- Wellens' syndrome
- Coronary artery vasospasm (eg, Prinzmetal's angina)
- Coronary artery dissection
- Pericarditis
- Myocarditis
- Aortic dissection in to coronary
- Left ventricular aneurysm
- Left ventricular pseudoaneurysm
- Early repolarization
- Left bundle branch block
- Left ventricular hypertrophy (LVH)
- Myocardial tumor
- Myocardial trauma
- RV pacing (appears as Left bundle branch block)
- Brugada syndrome
- Takotsubo cardiomyopathy
- AVR ST elevation
- Other thoracic
- Metabolic
- Drugs of abuse (eg, cocaine, crack, meth)
- Hyperkalemia (only leads V1 and V2)
- Hypothermia ("Osborn J waves")
- Medications
Evaluation
ECG Criteria
- Type 1
- Elevated ST segment (>2mm)
- Descends with upward convexity to a TWI
- Type 2
- Elevated ST segment (>1mm)
- Descends toward baseline then rises again (saddleback) to upright T wave
- Type 3
- Elevated ST segment (<1mm)
- Descends toward baseline then rises again to upright T wave
v1-v2 lead placement in 2nd or 3rd IC spaces (rather than conventional 4th IC space) increases chance of recording type I pattern[4]
ECG Unmasking Factors[5][6][7][8]
- Type 1 ECG findings can be transient and "unmasked" by the following:
Higher Risk ECG Features
- Early repolarization with J-point elevation in inferior leads (seen in 10% of Brugada syndrome)[10]
- QRS widening > 120 ms in V2[11]
- QRS fragmentation (additional QRS complex spikes)[12][13]
- ST elevation during recovery after exercise
Diagnosis
- Diagnosed when a patient has Burdada's ECG pattern (see above) AND documented ventricular tachydysrhythia or history consistent with ventricular tachydysrythmia (e.g. syncope, sudden cardiac death)[14]
Management
Acute ED management depends on presenting symptoms
Incidental Brugada Pattern on ECG (Otherwise Asymptomatic)
- No acute treatment
Concerning Cardiac Symptoms
- Cardiology consultation and likely admission
- Consider EP consult and VF-inducing electrophysiologic study (EPS), though EPS is controversial prognosticator[15]
Active Tachydysrhythmia
- Antidysrhythmics trials have inconsistently shown clinical benefit, but potential VF-terminating and prevention meds may include quinidine, isoproterenol[16]
- See electrical storm for 3 or more episodes of sustained ventricular tachycardia, ventricular fibrilation, or ICD shocks within 24 hours
Drugs to be Avoided
- If starting or using new med, check www.brugadadrugs.org drug list
- Commonly used meds to avoid include:
- Procainamide
- Bupivacaine
- Propofol
- Ketamine
- Tramadol
- Lithium
- Except for quinidine, class I antiarrhythmic drugs, particularly sodium channel blockers such as procainamide and flecainide should be avoided
- Certain antiepileptic medications
- Certain tricyclic antidepressants
- Certain SSRIs
Disposition
- Incidental finding with no suggestive family or patient history (e.g. syncope, tachydysrhythmia, sudden cardiac death)--> education and general cardiology referral[17]
- Suggestive family or patient history --> disposition in consultation with cardiology[18]
- Active tachydysrhythmia --> admission[19]
Inpatient vs Outpatient ICD Placement
External Links
See Also
References
- ↑ Paul M., Gerss J., Schulze-Bahr E.; Role of programmed ventricular stimulation in patients with Brugada syndrome: a meta-analysis of worldwide published data. Eur Heart J. 28 2007:2126-2133.
- ↑ Cerrato N, Giustetto C, et al. Prevalence of Type 1 Brugada Electrocardiographic Pattern Evaluated by Twelve-Lead Twenty-Four-Hour Holter Monitoring. The American Journal of Cardiology.115(1). 2015. 52-56.
- ↑ Richter S., Sarkozy A., Veltmann C.; Variability of the diagnostic ECG pattern in an ICD patient population with Brugada syndrome. J Cardiovasc Electrophysiol. 20 2009:69-75.
- ↑ Shimizu W., Matsuo K., Takagi M.; Body surface distribution and response to drugs of ST segment elevation in Brugada syndrome: clinical implication of eighty-seven-lead body surface potential mapping and its application to twelve-lead electrocardiograms. J Cardiovasc Electrophysiol. 11 2000:396-404.
- ↑ Ikeda T., Abe A., Yusu S.; The full stomach test as a novel diagnostic technique for identifying patients at risk of Brugada syndrome. J Cardiovasc Electrophysiol. 17 2006:602-607.
- ↑ Shimeno K., Takagi M., Maeda K., Tatsumi H., Doi A., Yoshiyama M.; Usefulness of multichannel Holter ECG recording in the third intercostal space for detecting type 1 Brugada ECG: comparison with repeated 12-lead ECGs. J Cardiovasc Electrophysiol. 20 2009:1026-1031.
- ↑ Keller D.I., Huang H., Zhao J.; A novel SCN5A mutation, F1344S, identified in a patient with Brugada syndrome and fever-induced ventricular fibrillation. Cardiovasc Res. 70 2006:521-529.
- ↑ ANTZELEVITCH, C., & BRUGADA, R. (2002). Fever and Brugada Syndrome. Pacing and Clinical Electrophysiology, 25(11), 1537–1539. doi:10.1046/j.1460-9592.2002.01537.x
- ↑ Makimoto H., Nakagawa E., Takaki H.; Augmented ST-segment elevation during recovery from exercise predicts cardiac events in patients with Brugada syndrome. J Am Coll Cardiol. 56 2010:1576-1584.
- ↑ Sarkozy A., Chierchia G.B., Paparella G.; Inferior and lateral electrocardiographic repolarization abnormalities in Brugada syndrome. Circ Arrhythm Electrophysiol. 2 2009:154-161.
- ↑ Junttila M.J., Brugada P., Hong K.; Differences in 12-lead electrocardiogram between symptomatic and asymptomatic Brugada syndrome patients. J Cardiovasc Electrophysiol. 19 2008:380-383.
- ↑ Take Y and Morita H. Fragmented QRS: What Is The Meaning? Indian Pacing Electrophysiol J. 2012 Sep-Oct; 12(5): 213–225.
- ↑ Morita H., Kusano K.F., Miura D.; Fragmented QRS as a marker of conduction abnormality and a predictor of prognosis of Brugada syndrome. Circulation. 118 2008:1697-1704.
- ↑ M Sharon, et al. ECG of the Month. Annals of Emergency Medicine. December 2019. 74(6);782-785
- ↑ Viskin S and Rosso R. Risk of Sudden Death in Asymptomatic Brugada Syndrome: Not as High as We Thought and Not as Low as We Wished…But the Contrary. J Am Coll Cardiol. 2010;56(19):1585-1588.
- ↑ Postema PG, Wolpert C, Amin AS, Probst V, Borggrefe M, Roden DM, et al. Drugs and Brugada syndrome patients: review of the literature, recommendations, and an up-to-date website (www.brugadadrugs.org). Heart Rhythm. 2009 Sep. 6(9):1335-41.
- ↑ M Sharon, et al. ECG of the Month. Annals of Emergency Medicine. December 2019. 74(6);782-785
- ↑ M Sharon, et al. ECG of the Month. Annals of Emergency Medicine. December 2019. 74(6);782-785
- ↑ M Sharon, et al. ECG of the Month. Annals of Emergency Medicine. December 2019. 74(6);782-785
- ↑ Sacher F., Probst V., Iesaka Y.; Outcome after implantation of a cardioverter-defibrillator in patients with Brugada syndrome: a multicenter study. Circulation. 114 2006:2317-2324.
- ↑ Rosso R., Glick A., Glikson M.; Outcome after implantation of cardioverter defibrillator in patients with Brugada syndrome: a multicenter Israeli study (ISRABRU). Isr Med Assoc J. 10 2008:435-439.