So what is Brugada Syndrome?

It’s an inherited sodium channelopathy, associated with sudden death and syncope due to polymorphic VT and, as in our case, VF. 
Three types of ECG pattern are describe in Brugada, although only type 1 is considered diagnostic, as shown in our ECG.  

Type 1 ECG pattern:

  • Cove-shaped ST elevation of at least 2mm followed by a negative T wave in one or more of leads V1-3

In conjuction with these ECG features you need, at least, one of the following:

  • Document VF / polymorphic VT
  • Family history of sudden cardiac death at <45 years
  • Type 1 pattern ECG i n family members
  • Inducibility of VT with programmed stimulation
  • Syncope
  • Nocturnal agonal respiration
    • Attributed to self-terminating VF/polymorphic VT

The above diagnostic criteria are taken from the CSANZ (Cardiac Society of Australia and New Zealand) Guidelines for the diagnosis and management of Brugada syndrome, this document is well worth a read as it covers pathophysiology, diagnostic criteria, management, and includes examples of the type 2 and type 3 ECG patterns. 

Also check out the following great blog posts on Brugada:

What can/should we do about it ?

As an emergency physician encountering a case of suspected / likely Brugada it’s easy, phone your cardiologist. For those patients with a Brugada pattern ECG with a history of syncope, arrest, or arrhythmias, definitive treatment is an AICD insertion. The incidental Brugada pattern in the otherwise well patient is a bit more controversial, again from an Emergency Medicine perspective phone your cardiology team. The CSANZ guidelinecontains a nice algorithm for the diagnostic approach to Brugada and also discusses management strategies in the incidental and asymptomatic Brugada.

We should also be aware that some drugs can cause Brugada-like ECG changes and should be avoided in patients with known or suspected Brugada. For more information on what not to give go to www.brugadadrugs.org which contains information for both clinicians and patients.

Check out these cases from Dr Smith’s blog (Case 1 and Case 2) which illustrate Brugada-like changes secondary to drug therapy.

Avoiding certain drugs raises the question what should we give ?

The simple answer is electricity in the setting of acute arrhythmia. 
In those patients experiencing an arrythmic storm, or having repeated ICD shocks then iv isoprenaline has been proven to be useful and is recommended in the CSANZ guidelines.
For chronic prevention of arrhythmia the only oral agent shown to work is quinidine, but this is often very difficult to source.

Ii is also worth noting that fever can unmask Brugada, due to impaired sodium channel function and aggressive management of fever should be instigated. Other potential precipitants include alcohol, hypokalaemia, cocaine, large carb meals, and very hot baths.

But I’ll never see it ?

  • The simple answer to this is that it’s entirely possible you will.
  • The issue is will you recognise it?

I work in a district general Emergency Department seeing ~90,000 attendances a year across a mixed population. This year alone I’m aware of at least 3 cases of Brugada that have been diagnosed in our Emergency Department. 
This is an ECG pattern we must be aware of and understand the implications it has for the patient and what needs to happen next. 
This isn’t small print stuff, this isn’t once a career pick-up, this is a real condition that you can easily encounter in any ED, at any time.