Available online at www.sciencedirect.com
ScienceDirect Journal of Electrocardiology 47 (2014) 362 – 363 www.jecgonline.com
Brugada electrocardiographic pattern: Reality or fiction? Javier García-Niebla, RN, a,⁎ Guillem Serra-Autonell, MD, b Miquel Fiol, MD, PhD, c Antonio Bayés de Luna, MD, PhD d a
Servicios Sanitarios del Área de Salud de El Hierro, Valle del Golfo Health Center, Islas Canarias, Spain b Gem-Med S.L., Barcelona, Spain c Hospital Universitario Son Espases, Unidad Coronaria, Palma de Mallorca, Spain d Institut Catala d’Ciencies Cardiovasculars, Hospital Santa Creu i Sant Pau, Barcelona, Spain
Abstract
In many cases, failure to perform an electrocardiogram according to established standards can lead to incorrect diagnosis. When this error involves a disease that can result in sudden death such as Brugada syndrome, diagnostic procedures are not without risk for the patient. A 20 year-old man visited his family doctor for atypical chest pain some time before. Electrocardiography (ECG) showed sinus rhythm of 47 bpm with striking ST-elevation in V1–V3 suggestive of the Brugada pattern. Sometimes, the different low-frequency components of the ECG, such as the ST segment, may be distorted by high cutoff filters resulting in diagnostic errors [Am J Cardiol 2012;110:318–320]. Faced with an apparent Brugada syndrome pattern on ECG, clinicians should ensure the recording was correctly made. © 2014 Elsevier Inc. All rights reserved.
Keywords:
Electrocardiogram; Brugada syndrome; Sudden death
In many cases, failure to perform an electrocardiogram according to established standards can lead to incorrect diagnosis [1]. When this error involves a disease that can result in sudden death such as Brugada syndrome, diagnostic procedures are not without risk for the patient. A 20 year-old man visited his family doctor for atypical chest pain some time before. The patient was asymptomatic. Physical examination showed blood pressure 120/70 mm Hg, heart rate 50 bpm and temperature 36.2 °C. Heart and lung auscultation was normal. He had no family history of sudden death and was not taking any medication. Electrocardiography (ECG) showed sinus rhythm of 47 bpm with striking ST-elevation in V1–V3 suggestive of the Brugada pattern [2] (Fig. 1A). The coved morphology diagnostic of type 1 Brugada syndrome is only present in V1, while a saddle-back pattern can be seen in V2–V3. The patient was referred to the hospital cardiology department where a new ECG (Fig. 1B) showed sinus rhythm without alterations in V1–V3. High placement of the precordial electrodes on the 2nd and 3rd intercostal spaces failed to reproduce the initial pattern. Echocardiogram and Holter results were normal and flecainide test was negative. Retrospective analysis showed
that the initial ECG was performed using a very high cutoff (0.1 Hz) high-pass filter in contrast to the subsequent ECG where the high pass filter cutoff was lower and closer to standard values [3]. Sometimes, the different low-frequency components of the ECG, such as the ST segment, may be distorted by high cutoff filters resulting in diagnostic errors [4] leading to unnecessary therapeutic measures [5] that may involve risk for the patient. The negative flecainide test result ruled out a diagnosis of Brugada syndrome and, therefore, the dynamic form of presentation. In our case, if the improper filter setting had been recognized right at the start, the ECG would have been repeated immediately using a cut-off of 0.05 Hz. If the pattern suggestive of Brugada syndrome had disappeared in the second ECG, flecainide test would not have been necessary. A direct comparison should have been made with the same machine and different filter settings, as well as ensuring the same precordial electrode placement. Faced with an apparent Brugada syndrome pattern on ECG, clinicians should ensure the recording was correctly made. References
⁎ Corresponding author at: Valle del Golfo Health Center, C/Marcos Luis Barrera 1, 38911 Frontera-El Hierro, Islas Canarias, Spain. E-mail address: [email protected] 0022-0736/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jelectrocard.2014.02.011
[1] García-Niebla J, Llontop-García P, Valle-Racero JI, Serra-Autonell G, Batchvarov VN, de Luna AB. Technical mistakes during the acquisition of the electrocardiogram. Ann Noninvasive Electrocardiol 2009;14: 389–403.
J. García-Niebla et al. / Journal of Electrocardiology 47 (2014) 362–363
363
Fig. 1. Electrocardiogram of an asymptomatic 20 year-old man with striking ST-elevation in V1–V3 suggestive of the Brugada pattern, improperly filtered (Panel A) using 0.1 Hz. Notice how after the application of a cutoff of 0.08 Hz the Brugada pattern is no longer seen (Panel B).
[2] Bayés de Luna A, Brugada J, Baranchuk A, Borggrefe M, Breithardt G, Goldwasser D, et al. Current electrocardiographic criteria for diagnosis of Brugada pattern: a consensus report. J Electrocardiol 2012;45:433–42. [3] Kligfield P, Gettes LS, Bailey JJ, Childers R, Deal BJ, Hancock EW, et al. Recommendations for the standardization and interpretation of the electrocardiogram, part I: the electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the
American College of Cardiology Foundation; and the Heart Rhythm Society. Circulation 2007;115:1306–24. [4] García-Niebla J, Serra-Autonell G, Bayés de Luna A. Brugada syndrome electrocardiographic pattern as a result of improper application of a highpass filter. Am J Cardiol 2012;110:318–20. [5] Knight BP, Pelosi F, Michaud GF, Strickberger SA, Morady F. Clinical consequences of electrocardiographic artifact mimicking ventricular tachycardia. N Engl J Med 1999;341:1270–4.
ScienceDirect Journal of Electrocardiology 47 (2014) 362 – 363 www.jecgonline.com
Brugada electrocardiographic pattern: Reality or fiction? Javier García-Niebla, RN, a,⁎ Guillem Serra-Autonell, MD, b Miquel Fiol, MD, PhD, c Antonio Bayés de Luna, MD, PhD d a
Servicios Sanitarios del Área de Salud de El Hierro, Valle del Golfo Health Center, Islas Canarias, Spain b Gem-Med S.L., Barcelona, Spain c Hospital Universitario Son Espases, Unidad Coronaria, Palma de Mallorca, Spain d Institut Catala d’Ciencies Cardiovasculars, Hospital Santa Creu i Sant Pau, Barcelona, Spain
Abstract
In many cases, failure to perform an electrocardiogram according to established standards can lead to incorrect diagnosis. When this error involves a disease that can result in sudden death such as Brugada syndrome, diagnostic procedures are not without risk for the patient. A 20 year-old man visited his family doctor for atypical chest pain some time before. Electrocardiography (ECG) showed sinus rhythm of 47 bpm with striking ST-elevation in V1–V3 suggestive of the Brugada pattern. Sometimes, the different low-frequency components of the ECG, such as the ST segment, may be distorted by high cutoff filters resulting in diagnostic errors [Am J Cardiol 2012;110:318–320]. Faced with an apparent Brugada syndrome pattern on ECG, clinicians should ensure the recording was correctly made. © 2014 Elsevier Inc. All rights reserved.
Keywords:
Electrocardiogram; Brugada syndrome; Sudden death
In many cases, failure to perform an electrocardiogram according to established standards can lead to incorrect diagnosis [1]. When this error involves a disease that can result in sudden death such as Brugada syndrome, diagnostic procedures are not without risk for the patient. A 20 year-old man visited his family doctor for atypical chest pain some time before. The patient was asymptomatic. Physical examination showed blood pressure 120/70 mm Hg, heart rate 50 bpm and temperature 36.2 °C. Heart and lung auscultation was normal. He had no family history of sudden death and was not taking any medication. Electrocardiography (ECG) showed sinus rhythm of 47 bpm with striking ST-elevation in V1–V3 suggestive of the Brugada pattern [2] (Fig. 1A). The coved morphology diagnostic of type 1 Brugada syndrome is only present in V1, while a saddle-back pattern can be seen in V2–V3. The patient was referred to the hospital cardiology department where a new ECG (Fig. 1B) showed sinus rhythm without alterations in V1–V3. High placement of the precordial electrodes on the 2nd and 3rd intercostal spaces failed to reproduce the initial pattern. Echocardiogram and Holter results were normal and flecainide test was negative. Retrospective analysis showed
that the initial ECG was performed using a very high cutoff (0.1 Hz) high-pass filter in contrast to the subsequent ECG where the high pass filter cutoff was lower and closer to standard values [3]. Sometimes, the different low-frequency components of the ECG, such as the ST segment, may be distorted by high cutoff filters resulting in diagnostic errors [4] leading to unnecessary therapeutic measures [5] that may involve risk for the patient. The negative flecainide test result ruled out a diagnosis of Brugada syndrome and, therefore, the dynamic form of presentation. In our case, if the improper filter setting had been recognized right at the start, the ECG would have been repeated immediately using a cut-off of 0.05 Hz. If the pattern suggestive of Brugada syndrome had disappeared in the second ECG, flecainide test would not have been necessary. A direct comparison should have been made with the same machine and different filter settings, as well as ensuring the same precordial electrode placement. Faced with an apparent Brugada syndrome pattern on ECG, clinicians should ensure the recording was correctly made. References
⁎ Corresponding author at: Valle del Golfo Health Center, C/Marcos Luis Barrera 1, 38911 Frontera-El Hierro, Islas Canarias, Spain. E-mail address: [email protected] 0022-0736/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jelectrocard.2014.02.011
[1] García-Niebla J, Llontop-García P, Valle-Racero JI, Serra-Autonell G, Batchvarov VN, de Luna AB. Technical mistakes during the acquisition of the electrocardiogram. Ann Noninvasive Electrocardiol 2009;14: 389–403.
J. García-Niebla et al. / Journal of Electrocardiology 47 (2014) 362–363
363
Fig. 1. Electrocardiogram of an asymptomatic 20 year-old man with striking ST-elevation in V1–V3 suggestive of the Brugada pattern, improperly filtered (Panel A) using 0.1 Hz. Notice how after the application of a cutoff of 0.08 Hz the Brugada pattern is no longer seen (Panel B).
[2] Bayés de Luna A, Brugada J, Baranchuk A, Borggrefe M, Breithardt G, Goldwasser D, et al. Current electrocardiographic criteria for diagnosis of Brugada pattern: a consensus report. J Electrocardiol 2012;45:433–42. [3] Kligfield P, Gettes LS, Bailey JJ, Childers R, Deal BJ, Hancock EW, et al. Recommendations for the standardization and interpretation of the electrocardiogram, part I: the electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the
American College of Cardiology Foundation; and the Heart Rhythm Society. Circulation 2007;115:1306–24. [4] García-Niebla J, Serra-Autonell G, Bayés de Luna A. Brugada syndrome electrocardiographic pattern as a result of improper application of a highpass filter. Am J Cardiol 2012;110:318–20. [5] Knight BP, Pelosi F, Michaud GF, Strickberger SA, Morady F. Clinical consequences of electrocardiographic artifact mimicking ventricular tachycardia. N Engl J Med 1999;341:1270–4.
