What should be the appropriate management?
A. He should be referred for primary angioplasty
B. His temperature may have exacerbated his ECG changes
C. He should be treated with ajmaline
D. He needs an ICD
E. Beta-blockers are indicated
B. His temperature may have exacerbated his ECG changes.
Discussion: his ECG is highly suggestive of Brugada syndrome with a type 1 pattern, i.e. >2 mm
ST elevation in the J point, downsloping ST elevation, and inverted T waves best seen in
lead V2. The ECG changes can certainly be brought about by fevers, and therefore B is
the correct answer. There is no description of syncope and therefore the patient does not
meet the criteria for considering an ICD. Ajmaline is not a treatment for Brugada! It is a
test for people with type 2 or type 3 Brugada pattern on ECG to provoke a type 1 pattern,
but should not be given to people who already have a type 1 pattern as it may provoke
dangerous arrhythmias. There is no well-established medical therapy for Brugada syndrome
although trials with quinidine are under way.
Brugada syndrome is a disorder characterized by sudden death associated with one of several ECG patterns characterized by incomplete right bundle-branch block and ST-segment elevations in the anterior precordial leads
- Syncope and cardiac arrest: Most common clinical manifestations; in many cases, cardiac arrest occurs during sleep or rest
- Nightmares or thrashing at night
- Asymptomatic, but routine ECG shows ST-segment elevation in leads V1-V3
- Associated atrial fibrillation (20%)
- Fever: Often reported to trigger or exacerbate clinical manifestations