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Brugada Syndrome

Brugada syndrome

Mysterious Sudden Deaths
Brugada Syndrome
ECG and Brugada Syndrome
Type I - Brugada Syndrome
Type II - Brugada Syndrome
Type III - Brugada Syndrome
ECG Sensitivity and Brugada Syndrome
Diagnosis of Brugada Syndrome

Mysterious Sudden Deaths

The Brugada Brothers published a 1992 paper

In which they described sudden deaths in young healthy men in Southeast Asia
The young men had EKG changes similar to right ventricular infarction

The Brugada brothers demonstrated that it is not an infarction

Today, the condition is known as Brugada Syndrome

Brugada Syndrome

Prevalence: 5-50 per 10,000 (Most common in Southeast Asia)
Globally causes 4-12% of sudden cardiac deaths
It is a channelopathy (a congenital disorder of ion channels)

There is an altered action potential

It is autosomal dominant

If one parent has Brugada syndrome, each child has a 50% chance of inheriting the syndrome

Brugada syndrome poses a risk of malignant arrhythmia:

Malignant arrhythmia most commonly occurs:

In men aged 30-40 years
During rest or sleep, possibly due to higher vagal tone. (Does not occur during physical activity)

The only effective treatment is ICD (Implantable Cardioverter-Defibrillator)

ECG and Brugada Syndrome (V1-V3)

Changes are seen in precordial leads V1-V3

At least in 2 adjacent leads

According to ECG we distinguish 3 types of Brugada syndrome

There are about 60 gene mutations in ion channels
Types can alternate in a single patient

ECG findings may transiently disappear
Brugada syndrome on ECG is unmasked by:

A variety of medications (BrugadaDrugs.org)

Sodium channel blockers

Ischemia
Temperature
Alcohol
Increases the risk of malignant arrhythmia

Type I - Brugada Syndrome (V1-V3)

Changes are observed in V1-V3

J point ≥ 2mm
Negative T wave
Descending ST segment

Type II - Brugada Syndrome (V1-V3)

Changes are observed in V1-V3

J point ≥ 2mm
ST elevation ≥ 1mm
Positive or biphasic T wave

Type III - Brugada Syndrome (V1-V3)

Changes are in V1-V3

J point ≤ 1mm
ST elevation ≥ 1mm
Negative or positive T wave

ECG Sensitivity and Brugada Syndrome

For ECG diagnosis of Brugada syndrome, ECG leads V1 and V2 are moved to the 2nd intercostal space

ECG diagnosis of Brugada syndrome, ECG leads V1 and V2 are moved to the 2nd intercostal space

Leads V1-V2 and Brugada Syndrome

ECG signs of Brugada syndrome are highlighted

By moving leads V1-V2 to the 2nd intercostal space

4th intercostal space (standardly placed ECG leads)

In V1-2, Type I Brugada syndrome is indicated

2nd intercostal space

Leads V1-2 were moved up to the 2nd intercostal space
Type I Brugada syndrome was uncovered

Diagnosis of Brugada Syndrome

Brugada syndrome must have the mentioned ECG signs + clinical manifestations

Applies only to Type I
Types II and III must undergo electrophysiological examination and provocative tests

A patient with Type I must have at least one clinical sign:

Previous ventricular fibrillation
Previous polymorphic ventricular tachycardia
Sudden cardiac death in the family at age < 45 years
Brugada ECG signs in a family member
Inducibility of ventricular tachycardia by programmed electrical stimulation
Previous syncope
Nocturnal gasping (agonal) breathing

ECG criteria Brugada syndrom type I, type II, type III

Brugada Syndrome

This is an ECG from 3 different patients
The ECG recordings show Type I, II, and III of Brugada syndrome

ECG criteria Brugada syndrom type 1, type 2, type 3

Brugada Syndrome

These are ECGs from 3 different patients
The ECG recordings show Type I, II, and III Brugada Syndrome

Brugada Syndrome Type I

Changes are in V1 (V2)

J point ≥ 2mm
Negative T wave
Descendant ST segment

Brugada Syndrome Type I

Changes are in V1-V2

J point ≥ 2mm
Negative T wave
Descendant ST segment

ECG criteria Brugada syndrome type 2, J wave, ST segment, T wave

Brugada Syndrome Type II

Changes are in V2

J point ≥ 2mm
ST elevation ≥ 1mm
Positive or biphasic T wave

ECG criteria Brugada syndrome type 3, J wave, ST segment, T wave

Brugada Syndrome Type III

Changes are in V1-V3

J point ≤ 1mm
ST elevation ≥ 1mm
Negative or positive T wave

Acute STEMI infarction right ventriculcular, and inferior STEMI infarction, acute proximal occlusion right coronary artery

STEMI of the Right Ventricle

ST elevation in V1-V2
ST elevation in the inferior leads (II, III, aVF)
The patient has acute STEMI of the inferior wall and right ventricle

It is a proximal occlusion of the right coronary artery

Critical proximal LAD stenosis, Wellens' syndrome

ECG Wellens syndrome type 2, deeply inverted or biphasic T waves in V2-3

Wellens' Syndrome Type II

Biphasic T waves (V2-V3)

The first part is positive, the second part is negative

Minimal ST elevation < 1mm
The patient has Wellens' Syndrome Type II

It indicates critical stenosis of the proximal LAD
Patients are often asymptomatic and may develop anterior STEMI within about a week

Sources

ECG from Basics to Essentials Step by Step
litfl.com
ecgwaves.com
metealpaslan.com
medmastery.com
uptodate.com
ecgpedia.org
wikipedia.org
Strong Medicine
Understanding Pacemakers

Home /

Brugada Syndrome

Brugada syndrome

Mysterious Sudden Deaths
Brugada Syndrome
ECG and Brugada Syndrome
Type I - Brugada Syndrome
Type II - Brugada Syndrome
Type III - Brugada Syndrome
ECG Sensitivity and Brugada Syndrome
Diagnosis of Brugada Syndrome

Mysterious Sudden Deaths

The Brugada Brothers published a 1992 paper

In which they described sudden deaths in young healthy men in Southeast Asia
The young men had EKG changes similar to right ventricular infarction

The Brugada brothers demonstrated that it is not an infarction

Today, the condition is known as Brugada Syndrome

Brugada Syndrome

Prevalence: 5-50 per 10,000 (Most common in Southeast Asia)
Globally causes 4-12% of sudden cardiac deaths
It is a channelopathy (a congenital disorder of ion channels)

There is an altered action potential

It is autosomal dominant

If one parent has Brugada syndrome, each child has a 50% chance of inheriting the syndrome

Brugada syndrome poses a risk of malignant arrhythmia:

Malignant arrhythmia most commonly occurs:

In men aged 30-40 years
During rest or sleep, possibly due to higher vagal tone. (Does not occur during physical activity)

The only effective treatment is ICD (Implantable Cardioverter-Defibrillator)

ECG and Brugada Syndrome (V1-V3)

Changes are seen in precordial leads V1-V3

At least in 2 adjacent leads

According to ECG we distinguish 3 types of Brugada syndrome

There are about 60 gene mutations in ion channels
Types can alternate in a single patient

ECG findings may transiently disappear
Brugada syndrome on ECG is unmasked by:

A variety of medications (BrugadaDrugs.org)

Sodium channel blockers

Ischemia
Temperature
Alcohol
Increases the risk of malignant arrhythmia

Type I - Brugada Syndrome (V1-V3)

Changes are observed in V1-V3

J point ≥ 2mm
Negative T wave
Descending ST segment

Type II - Brugada Syndrome (V1-V3)

Changes are observed in V1-V3

J point ≥ 2mm
ST elevation ≥ 1mm
Positive or biphasic T wave

Type III - Brugada Syndrome (V1-V3)

Changes are in V1-V3

J point ≤ 1mm
ST elevation ≥ 1mm
Negative or positive T wave

ECG Sensitivity and Brugada Syndrome

For ECG diagnosis of Brugada syndrome, ECG leads V1 and V2 are moved to the 2nd intercostal space

ECG leads 4th intercostal space, Brugada syndrome (V1,V2)

Chest electrodes Brugada syndrome (V1, V2), changed V1, V2 positions to 2nd intercostal space

Changed lead positions of leads V1,V2 to increase the sensitivity to detect a Brugada pattern on the ECG

Leads V1-V2 and Brugada Syndrome

ECG signs of Brugada syndrome are highlighted

By moving leads V1-V2 to the 2nd intercostal space

4th intercostal space (standardly placed ECG leads)

In V1-2, Type I Brugada syndrome is indicated

2nd intercostal space

Leads V1-2 were moved up to the 2nd intercostal space
Type I Brugada syndrome was uncovered

Diagnosis of Brugada Syndrome

Brugada syndrome must have the mentioned ECG signs + clinical manifestations

Applies only to Type I
Types II and III must undergo electrophysiological examination and provocative tests

A patient with Type I must have at least one clinical sign:

Previous ventricular fibrillation
Previous polymorphic ventricular tachycardia
Sudden cardiac death in the family at age < 45 years
Brugada ECG signs in a family member
Inducibility of ventricular tachycardia by programmed electrical stimulation
Previous syncope
Nocturnal gasping (agonal) breathing

Brugada Syndrome

This is an ECG from 3 different patients
The ECG recordings show Type I, II, and III of Brugada syndrome

Brugada Syndrome

These are ECGs from 3 different patients
The ECG recordings show Type I, II, and III Brugada Syndrome

Brugada Syndrome Type I

Changes are in V1 (V2)

J point ≥ 2mm
Negative T wave
Descendant ST segment

Brugada Syndrome Type I

Changes are in V1-V2

J point ≥ 2mm
Negative T wave
Descendant ST segment

Brugada Syndrome Type II

Changes are in V2

J point ≥ 2mm
ST elevation ≥ 1mm
Positive or biphasic T wave

Brugada Syndrome Type III

Changes are in V1-V3

J point ≤ 1mm
ST elevation ≥ 1mm
Negative or positive T wave

STEMI of the Right Ventricle

ST elevation in V1-V2
ST elevation in the inferior leads (II, III, aVF)
The patient has acute STEMI of the inferior wall and right ventricle

It is a proximal occlusion of the right coronary artery

Wellens' Syndrome Type II

Biphasic T waves (V2-V3)

The first part is positive, the second part is negative

Minimal ST elevation < 1mm
The patient has Wellens' Syndrome Type II

It indicates critical stenosis of the proximal LAD
Patients are often asymptomatic and may develop anterior STEMI within about a week

Sources

ECG from Basics to Essentials Step by Step
litfl.com
ecgwaves.com
metealpaslan.com
medmastery.com
uptodate.com
ecgpedia.org
wikipedia.org
Strong Medicine
Understanding Pacemakers