A 25-year-old otherwise healthy male patient form Thailand
presents with 5 day history of a mild shortness of breath, without chest pain.
He gives history of travel recently from Thailand to the UAE about 15 days ago.
The vital signs were stable. A chest x-ray appears to be normal. His wells
score for DVT is low. D dimer levels were found to be 400 units. An
electrocardiogram (EKG) is ordered and is shown in Figure below. Which of the
following is most likely?
Multiple
Choice Responses
1 The
patient's potassium level is decreased.
2 The
patient has an increased risk for sudden cardiac death.
3 An
echocardiogram would likely reveal significant underlying structural heart
disease.
4 The
patient has an ST-elevation myocardial
infarction (STEMI) and needs an emergent heart catheterization.
5 The
possibility of pulmonary embolism is high and the patient needs CT angiography
Answer:
This patient’s EKG reveals classic or “type 1” Brugada
syndrome. Brugada syndrome is characterized by a pseudo-RBBB and persistent ST
elevation in V1–V3. There are three unique patterns of ST elevation consistent
with Brugada syndrome. In type 1, the elevated ST segment is convex facing
upward, and gradually descends to an inverted T wave. This is referred to as a
“coved type” Brugada pattern, and is most common. Types 2 and 3 have identical
patterns, in which the elevated ST segment (>1 mm in type 2, >1 mm in
type 3) first descends and then rises again after nearing the baseline,
creating a “saddle back” appearance. It is associated with an upright or
biphasic T wave. Brugada syndrome is not normally associated with any
structural abnormalities. Most “standard” cardiac tests, including
echocardiography, stress testing, and cardiac MRI are unrevealing. However, patients
are at a much increased risk for sudden cardiac arrest due to ventricular
arrhythmias. Unlike patients with hypertrophic obstructive
cardiomyopathy, sudden cardiac arrest is not typically due to exercise and more
commonly occurs in sleep. Most patients with Brugada syndrome undergo
electrophysiology testing to determine their risk for cardiac arrest as well as
the need for an automated implantable cardioverter-defibrillator.
Further Reading Medscape
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