Wednesday, August 8, 2012

ECG Interpretation Review #50 (Syncope - STEMI - MI - Brugada - RBBB - Early Repolarization)

The ECG shown was obtained from a 62-year-old man who presented to the ED (Emergency Department) with a history of several presyncopal episodes in recent months. His ECG was diagnosed as showing acute anterior STEMI (ST Elevation Myocardial Infarction). 
  • Do you agree? 
  • What treatment is indicated?

Figure: ECG obtained from a 62 year-old man with a history of presyncopal episodes. 

INTERPRETATION: The ECG shows sinus bradycardia at a rate just under 60/minute. All intervals and the axis are normal. There is no chamber enlargement. There may be slight J-point ST elevation in lead I, and some nonspecific ST depression in inferior and lateral precordial leads. That said – the area of most concern clearly relates to findings in leads V1 and V2.
  • There appears to be an rSr’ complex in V1,V2.
  • There is an elevated J-point in each of these leads – with an unusual type of downsloping ST segment that is especially marked in lead V2. The ST segment terminates in shallow T wave inversion.
  • The ECG findings in the Figure are highly suggestive of Brugada Syndrome. First described in 1992 — the Brugada syndrome is important to recognize because of an associated very high risk of sudden death. The prevalence of this disorder is approximately 1/2000 in the general population. Brugada syndrome is a leading cause of sudden death in adults under 40.
BOTTOM LINE: Although serial tracings and troponins are advised — the ECG in the Figure is not suggestive of acute STEMI. It is also not representative of RBBB (Right Bundle Branch Block). Instead, especially in view of the history of several recent presyncopal episodes (!) — the tracing suggests Brugada Syndrome
  • Cardiology consult should be obtained.
  • ICD (Implantable Cardioverter-Defibrillator) placement should be considered, pending results of careful evaluation.


ACKNOWLEDGMENT: My appreciation goes to Dr. Harsha Nagarajarao (of Cardiology Boards) for allowing me to use this tracing.

For more on Brugada SyndromeSee ECG Blog #238

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  1. What about the Brugada Pattern The typical changes in V1 and /V2 may be seen transiently in patients with drug /toxin overdosages?

  2. Hello Dr. M. Mahesh. Yes, this ECG shows a typical Type I Brugada pattern in leads V1,V2. The link under references is to a brief summary pdf (from my ECG-2014-ePub) plus 2 wonderful references on the Brugada Syndrome. Yes, this may clearly be seen transiently in patients with drug/toxin overdose (as well as under a variety of other circumstances) — but the case in question was associated with pre-syncopal episodes, which is why it should be referred for full evaluation (and most probably implantation of an ICD). THANKS again for your comment.