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Syncope in Brugada syndrome type 3: an electrocardiographic lesson
American Journal of Emergency Medicine 31 (2013) 621–630
Contents lists available at SciVerse ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence Syncope in Brugada syndrome type 3: an electrocardiographic lesson☆,☆☆,★ To the Editor, We thank Grossman et al. [1] for their wonderful article on the incidence of critical interventions or adverse outcomes associated with near syncope comparing these outcomes with the ones of patients with true syncope. In addition, we would like to emphasize that physicians should further evaluate for arrhythmias in patients with either near syncope or true syncope based on electrocardiographic (ECG) findings.
We recently had a case of a 63-year-old white woman with medical history significant for hypertension presented to the emergency department with an episode of syncope. Over the previous several months, the patient had multiple episodes of lightheadedness, which are not related to each other. Her physical examination including orthostatic vitals, laboratory work, computed tomography of head, cardiac enzymes, transthoracic echocardiogram, 24-hour telemetry monitoring, and Holter monitoring was unremarkable. She did not have another episode of light headedness during this period. The cardiologist reviewed her several ECGs that were read as “INCOMPLETE RIGHT BUNDLE BRANCH BLOCK,” “NON
Fig. 1. Electrocardiogram 12 leads revealed “INCOMPLETE RIGHT BUNDLE BRANCH BLOCK,” “NON SPECIFIC INTRAVENTRICULAR CONDUCTION DELAY,” and “NON SPECIFIC ST-T ABNORMALITY” in leads V1 to V2.
☆ Funding: None. ☆☆ Conflict of interest: None. ★ Authorship: All authors participated in writing the manuscript and had access to data. The authors have no commercial associations or sources of support that might pose a conflict of interest. 0735-6757/$ – see front matter. Published by Elsevier Inc.
622
Correspondence / American Journal of Emergency Medicine 31 (2013) 621–630
Fig. 2. Electrocardiograms showed the classic “coved ST pattern,” characteristic of type 1 Brugada pattern.
SPECIFIC INTRAVENTRICULAR CONDUCTION DELAY,” and “NON SPECIFIC ST-T ABNORMALITY” in leads V1 to V2 (Fig. 1). We also elicited further family history of the patient's mother passing away in her sleep. The patient underwent pharmacologic challenge test with Ajmaline, which showed the classic “coved ST pattern,” characteristic of type 1 Brugada pattern (Fig. 2). Considering family history, positive challenge test, and symptomatic with syncope, patient was given diagnosis of Brugada syndrome type 3. Brugada syndrome is associated with a peculiar pattern on the ECG consisting of a pseudo-right bundle branch block and persistent STsegment elevation in leads V1 to V3 [2]. Ventricular tachycardia may be dismissed as a cause of syncope in a structurally normal heart; however, there are exceptions to this rule as demonstrated in our case. Patients with Brugada syndrome do not have ventricular extrasystoles or nonsustained ventricular tachycardia at Holter monitoring. Therefore, the therapeutic approach for these patients is centered on prevention of cardiac arrest [3].
References [1] Grossman SA, Babineau M, Burke L, Kancharla A, Mottley L, Nencioni A, et al. Do outcomes of near syncope parallel syncope? Am J Emerg Med 2012;30(1):203–6. [2] Brugada P, Brugada J. Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. A multicenter report. J Am Coll Cardiol 1992;20(6):1391. [3] Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008;117(21):e350.
Adult intraosseous use in academic EDs and simulated comparison of emergent vascular access techniques☆,☆☆,★ To the Editor,
Saeed Ahmed MB, BS Supawat Ratanapo MD Saira Rashid MB, BS Wisit Cheungpasitporn MD Edward F. Bischof MD Department of Medicine Bassett Medical Center Cooperstown, NY, USA Jesse P. Cone MD Division of Cardiology Bassett Medical Center Cooperstown, NY, USA http://dx.doi.org/10.1016/j.ajem.2012.11.016
The military has seen a resurgence in the use of intraosseous (IO) devices; however, the extent of adult IO use in civilians is not well studied [1]. Emergent vascular access is crucial when caring for critical patients. Time to delivery of medications, fluids, and blood products can be vital for survival. Because of ease and speed, pediatric advanced life support (PALS) training advises IO access if intravenous (IV) access is unsuccessful after 2 attempts [2].
☆ There were no sources of support for this study. ☆☆ This research was presented at the American College of Emergency Physicians Research Forum, September 2010 in Las Vegas, NV. ★ Bloch SA, Bloch AJ, Silva P. Adult intraosseous use in academic emergency departments and simulated comparisons of emergency vascular access techniques. Ann Emerg Med 2010;56(3):S152.
Contents lists available at SciVerse ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Correspondence Syncope in Brugada syndrome type 3: an electrocardiographic lesson☆,☆☆,★ To the Editor, We thank Grossman et al. [1] for their wonderful article on the incidence of critical interventions or adverse outcomes associated with near syncope comparing these outcomes with the ones of patients with true syncope. In addition, we would like to emphasize that physicians should further evaluate for arrhythmias in patients with either near syncope or true syncope based on electrocardiographic (ECG) findings.
We recently had a case of a 63-year-old white woman with medical history significant for hypertension presented to the emergency department with an episode of syncope. Over the previous several months, the patient had multiple episodes of lightheadedness, which are not related to each other. Her physical examination including orthostatic vitals, laboratory work, computed tomography of head, cardiac enzymes, transthoracic echocardiogram, 24-hour telemetry monitoring, and Holter monitoring was unremarkable. She did not have another episode of light headedness during this period. The cardiologist reviewed her several ECGs that were read as “INCOMPLETE RIGHT BUNDLE BRANCH BLOCK,” “NON
Fig. 1. Electrocardiogram 12 leads revealed “INCOMPLETE RIGHT BUNDLE BRANCH BLOCK,” “NON SPECIFIC INTRAVENTRICULAR CONDUCTION DELAY,” and “NON SPECIFIC ST-T ABNORMALITY” in leads V1 to V2.
☆ Funding: None. ☆☆ Conflict of interest: None. ★ Authorship: All authors participated in writing the manuscript and had access to data. The authors have no commercial associations or sources of support that might pose a conflict of interest. 0735-6757/$ – see front matter. Published by Elsevier Inc.
622
Correspondence / American Journal of Emergency Medicine 31 (2013) 621–630
Fig. 2. Electrocardiograms showed the classic “coved ST pattern,” characteristic of type 1 Brugada pattern.
SPECIFIC INTRAVENTRICULAR CONDUCTION DELAY,” and “NON SPECIFIC ST-T ABNORMALITY” in leads V1 to V2 (Fig. 1). We also elicited further family history of the patient's mother passing away in her sleep. The patient underwent pharmacologic challenge test with Ajmaline, which showed the classic “coved ST pattern,” characteristic of type 1 Brugada pattern (Fig. 2). Considering family history, positive challenge test, and symptomatic with syncope, patient was given diagnosis of Brugada syndrome type 3. Brugada syndrome is associated with a peculiar pattern on the ECG consisting of a pseudo-right bundle branch block and persistent STsegment elevation in leads V1 to V3 [2]. Ventricular tachycardia may be dismissed as a cause of syncope in a structurally normal heart; however, there are exceptions to this rule as demonstrated in our case. Patients with Brugada syndrome do not have ventricular extrasystoles or nonsustained ventricular tachycardia at Holter monitoring. Therefore, the therapeutic approach for these patients is centered on prevention of cardiac arrest [3].
References [1] Grossman SA, Babineau M, Burke L, Kancharla A, Mottley L, Nencioni A, et al. Do outcomes of near syncope parallel syncope? Am J Emerg Med 2012;30(1):203–6. [2] Brugada P, Brugada J. Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. A multicenter report. J Am Coll Cardiol 1992;20(6):1391. [3] Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008;117(21):e350.
Adult intraosseous use in academic EDs and simulated comparison of emergent vascular access techniques☆,☆☆,★ To the Editor,
Saeed Ahmed MB, BS Supawat Ratanapo MD Saira Rashid MB, BS Wisit Cheungpasitporn MD Edward F. Bischof MD Department of Medicine Bassett Medical Center Cooperstown, NY, USA Jesse P. Cone MD Division of Cardiology Bassett Medical Center Cooperstown, NY, USA http://dx.doi.org/10.1016/j.ajem.2012.11.016
The military has seen a resurgence in the use of intraosseous (IO) devices; however, the extent of adult IO use in civilians is not well studied [1]. Emergent vascular access is crucial when caring for critical patients. Time to delivery of medications, fluids, and blood products can be vital for survival. Because of ease and speed, pediatric advanced life support (PALS) training advises IO access if intravenous (IV) access is unsuccessful after 2 attempts [2].
☆ There were no sources of support for this study. ☆☆ This research was presented at the American College of Emergency Physicians Research Forum, September 2010 in Las Vegas, NV. ★ Bloch SA, Bloch AJ, Silva P. Adult intraosseous use in academic emergency departments and simulated comparisons of emergency vascular access techniques. Ann Emerg Med 2010;56(3):S152.