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. (Reproduced from ECG-2014-ePub).  NOTE - Enlarge by clicking on Figures - Right-Click to open in a separate window.
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 – the tracing shows characteristic findings of Brugada Syndrome
  • Cardiology consult should be obtained.
  • ICD (Implantable Cardioverter-Defibrillator) placement is advised.
ACKNOWLEDGMENT: My appreciation goes to Dr. Harsha Nagarajarao (of Cardiology Boards) for allowing me to use this tracing.

For more on Brugada SyndromeClick on the icon:



  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.