Brugada Phenocopy: The Art of Recognizing the Brugada ECG Pattern

By Adrian Baranchuk

Brugada Phenocopy: The Art of Recognizing the Brugada ECG Pattern details all aspects associated with alternative diagnosis to Brugada Syndrome (BrS). Coverage includes how to identify the proper ECG pattern, what to do to investigate for BrP, and how to avoid misinterpretations and the use of unnecessary and expensive treatments. Chapters are written by experienced professionals, many of whom are colleagues that initially described this condition. This easy to use volume is a must have reference for researchers of cardiology, cardiologists, electrocardiologists, internists, emergency care doctors and students, residents and fellows.

• Assists in the proper recognition of the Brugada ECG patterns and how to distinguish true BrS from other conditions with identical ECG
• Expands understanding on how to properly recognize the ECG of Brugada patterns
• Contains access to a companion website with video to enhance understanding of proper measurement of the beta angle (Chevallier) and the base of the triangle (Serra)

• Language: English
• Publisher: Academic Press
• Release date: Mar 28, 2018
• ISBN: 9780128111529

Book preview

Brugada Phenocopy

The Art of Recognizing the Brugada ECG Pattern

Adrian Baranchuk MD FACC FRCPC FCCS

Professor of Medicine (Tenure)

Queen's University

Kingston, Ontario, Canada

Editor-in-Chief, Journal of Electrocardiology President, International Society of Electrocardiology Vice

President (Canada), Interamerican Society of Cardiology (SIAC)

Table of Contents

Cover

Title page

Table of Contents

Copyright

List of Contributors

Foreword

Preface

Chapter 1: The History of the Brugada Phenocopy Concept

Abstract

Introduction

Brugada syndrome (BrS)—the first consensus

Brugada syndrome—the second consensus

Brugada syndrome—the third consensus

Brugada Phenocopy (BrP)

Chapter 2: Brugada Phenocopy: Definition, Diagnosis, and Differentiation From True Brugada Syndrome

Abstract

Introduction to Brugada phenocopy

Classifying BrP

Diagnosis of BrP and its differentiation from BrS

The future of Brugada phenocopy

Chapter 3: The Value of the Sodium Channel Blocker Test in Brugada Syndrome and Brugada Phenocopy

Abstract

Introduction

Sodium channel blockers and Brugada syndrome

Sodium channel blockers and Brugada phenocopy

Similarities and differences between Brugada syndrome and Brugada phenocopy

Acknowledgment

Chapter 4: How to Recognize a Brugada ECG Pattern: The Beta Angle

Abstract

Acronyms

Chapter 5: How to Recognize a Brugada ECG Pattern: The Base of the Triangle

Abstract

Introduction

The differential diagnosis of RSr’ in the absence of structural heart disease

Conclusions

Chapter 6: The Rsr′ Pattern in Leads V1-V2: Algorithm and Differential Diagnosis

Abstract

Introduction

Causes of r′ (R′) in the precordial leads (V1-V2)

Pathological patterns

Clinical approach for the differential diagnosis of RSr′ pattern in lead V1: a proposed algorithm [14,15]

The importance of r′ in lead V1 to differentiate supraventricular arrhythmias

Summary

Chapter 7: International Registry and Educational Portal on Brugada Phenocopies

Abstract

Introduction

International Registry website—Welcome Tour

International Registry—categories and classification system

International Registry—2017 update

Future directions

Chapter 8: Specific Brugada Phenocopies: Ischemia

Abstract

The role of ischemia in BrS and BrP

Chapter 9: Specific Brugada Phenocopies: Acute Pulmonary Embolism

Abstract

Introduction

ECG manifestations of BrP in acute pulmonary embolism

Typical cases

Pathophysiological changes in acute pulmonary embolism

ECG manifestations and the possible mechanisms in acute pulmonary embolism

ECG differences between the Brugada syndrome and BrP in acute pulmonary embolism

ECG differences between the BrP in acute pulmonary embolism and anterior myocardial infarction

Chapter 10: Specific Brugada Phenocopies: Electrolyte and Metabolic Disorders

Abstract

Introduction

Common pathophysiology

Potassium imbalance

Conclusions

Acknowledgment

Chapter 11: The ECG of the Athlete and the Differential Diagnosis With the Brugada ECG Pattern

Abstract

Background

Type 1 pattern in athletes

Type 2 pattern in athletes

Early repolarization

Diagnostic approach

Conclusions

Chapter 12: The Value of the Vectorcardiogram in Brugada Syndrome

Abstract

Introduction

Vectorcardiographic features in the Brugada syndrome

Horizontal plane

Right sagittal plane

Discussion

Conclusions

Chapter 13: Exceptional Brugada Phenocopies

Abstract

Introduction

Conclusions

Chapter 14: Differentiation Between Brugada Syndrome and Brugada Phenocopy ECG Patterns: Is It Possible?

Abstract

Introduction

Expert interpretation

Electrocardiographic criteria

Conclusions

Chapter 15: The Future Is Here: Experimental Models and Genetics in Brugada Phenocopy

Abstract

Introduction

Experimental model of Brugada Phenocopy

Chapter 16: The Journey of Describing a New ECG Phenomenon

Abstract

Introduction and historical events

The journey of describing a new ECG phenomenon

Final considerations

Index

Copyright

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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

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ISBN: 978-0-12-811151-2

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List of Contributors

Bryce Alexander,     Kingston General Hospital, Queen’s University, Kingston, ON, Canada

Pavel Antiperovitch,     University of Western Ontario, London Health Sciences Centre, London, ON, Canada

Daniel D. Anselm,     Libin Cardiovascular Institute of Alberta, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada

Raimundo Barbosa-Barros,     Coronary Center of the Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Brazil

Héctor Barajas-Martinez,     Masonic Medical Research Laboratory, Utica, NY, United States

Adrian Baranchuk

Queen’s University, Kingston, ON, Canada

Kingston General Hospital, Queen’s University, Kingston, ON, Canada

Division of Cardiology, Queen’s University, Kingston, ON, Canada

Antoni Bayés de Luna,     Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, Barcelona, Spain

David G. Benditt,     University of Minnesota, Minneapolis, MN, United States

Eugene H. Chung,     Frankel Cardiovascular Center, University of Michigan Medical School, Ann Arbor, MI, United States

Gregory Dendramis,     Pietro Cosma Hospital, Camposampiero, Padova, Italy

Luis Alberto Escobar-Robledo,     Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, Barcelona, Spain

Javier García-Niebla,     Servicios Sanitarios Área de Salud de El Hierro, Valle del Golfo Health Center, Islas Canarias, Spain

Byron H. Gottschalk,     London Health Sciences Centre, Western University, London, ON, Canada

Dan Hu,     Masonic Medical Research Laboratory, Utica, NY, United States

Ankit Maheshwari,     University of Minnesota, Minneapolis, MN, United States

Albert Massó van Roessel,     Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, Barcelona, Spain

Andrés R. Pérez-Riera,     Design of Studies and Scientific Writing Laboratory at the ABC School of Medicine, Santo André, Brazil

Pieter G. Postema,     Heart Center, Academic Medical Center, Amsterdam, The Netherlands

Guillem Serra,     Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, Barcelona, Spain

Shiva Sreenivasan,     South West Acute Hospital, Western Health and Social Care Trust, Enniskillen, United Kingdom

Grace Xu,     Queen’s University, Kingston, ON, Canada

Zhong-Qun Zhan,     Shenzhen Guangming Central Hospital, Shenzhen City, China

Foreword

The value of telescopic learning and curiosity in research

Once upon a time, someone looked at the night sky and saw the moon. There was not only the Sun during the day, but there was the moon by night. That someone called her the Moon and hurried to tell it and show her to others next nights. Now many people in the village new about the existence of the Moon. In the next weeks to years all the inhabitants in the many villages of the island came to know about the Moon. And so went for a long time. It was like all knowledge about the night sky had been gathered. But some curious people started to look by night at the starry sky. There was more than The Moon. There were Stars. Later on, some of those who already knew about the Stars, and were curious, continued looking at the starry sky and discovered the Planets. Others looked longer and suggested that during the day the Sun, and by night the Moon, the Stars and the Planets moved around the island sky. Every new inhabitant of the island knew now about the Sun, the Moon, the Stars, and the Planets. Whether they were moving around the Earth or whether the Earth was actually turning around herself became an important point of discussion. But every child had just sucked as a sponge the knowledge of previous generations. The years that took to recognize the Moon were reduced now to milliseconds for a kid to recognize her. The same kid needs now a few hours to learn about the Stars, Planets, and the major principles of the Cosmos. This is what we can call telescopic learning; it is like every new student has a larger and larger telescope than his predecessors, making it easier and easier to see new details. Centuries of knowledge are absorbed at the speed of light. The progressively increasing capacity to absorb knowledge comes from this telescopic learning, which is also the basis for the progressive acceleration of the historical time. This progressive acceleration is also the cause of the progressive acceleration of knowledge. Telescopic learning is a fact about existing knowledge. The motor to new knowledge is something else: Curiosity, scientific curiosity.

What has all this to do with this book edited by Adrian Baranchuk? This book is about electrocardiography and vectorcardiography. The ECG having been successfully used now for more than 100 years, keeps on behaving as a fabulous source of information and research. Nobody knows exactly how many millions of ECGs are recorded daily. The large majority of physicians behave like the millions of people seeing the stars. Only a few look at them. The ones looking seriously recognize which stars they are, but that is all. Only a few have the necessary curiosity to keep on looking and search for the new. In electrocardiography these are people like Adrian and the coauthors of this superb book. Thus, the general principle of advancement in scientific knowledge is telescopic learning and curiosity. Just imagine yourself within the history from 1901 (the string galvanometer of Einthoven) to the book that you have in your hands now in 2018. From the ones that recorded the first electrical signals of the heart (Muirhead, Waller, Einthoven) who hardly could understand them to the accumulated knowledge of nowadays, the history of electrocardiography is not only fascinating but a real adventure. Adrian contributes with this book another chapter in this adventure.

I congratulate Adrian and his coauthors for this book, which, without any doubt, is born as a milestone in the history of electrocardiography. Of obligatory reading for everybody involved in Medicine, whatever the area of interest.

Pedro Brugada

Lede

February 1, 2018

Preface

The Brugada phencopy (BrP) concept was born in Brazil and created by an astute electrocardiologist, Prof. Dr. Andrés Pérez-Riera, an Argentinean national who has spent most of his academic and professional career in Sao Paulo, Brazil.

Pérez-Riera noted that several publications referred to the existence of different clinical conditions present with an identical Brugada ECG pattern but in response to an underlying clinical condition. He thought that environmental triggers were responsible to mimic a genetically predisposed condition. He coined the term BrP and published a case of a patient receiving propofol who has developed, during the infusion, a Brugada ECG pattern. This was the beginning.

This was a captivating idea to me and wanted to explore this condition in detail. After several months of trying to find the needle in the haystack, the first publication in the Annals of Noninvasive Electrocardiology brought several key players in Brugada syndrome together to support the concept of BrP and the new definitions.

One of the decisions of the group had major implications in the definition of BrP: all cases of Brugada ECG pattern unmasked by sodium-channel blockers would not be considered as BrP, but rather as a possibly unmasked true genetically determined BrS. This led to the classification of BrP that had to be revised a year later with a publication in the American Journal of Cardiology. Since then, as more and more authors started to report their cases, the classification kept growing. In 2014, we decided to create a website, which contains an educational portal and more importantly, the international registry on BrP. The website was visited more than 6000 times (www.brugadaphenocopy.com) and created a permanent vehicle for investigators to interact with us, seeking for advice, reporting their cases, and exchanging ideas about how to diagnose and categorize the risk of each individual case. The very same year, a publication in the Canadian Journal of Cardiology, advanced a morphological classification, which helps researchers to categorize each case and unify terminology.

The ECG remains the cornerstone diagnostic method to suspect both Brugada syndrome and BrP. It is the clinical ability and the results of the sodium blocker challenge test, which helps discriminating one entity from another. The efforts of our team, in the first 5 years of life of BrP, were directed to help the physician in this regard. We still believe that educating the community in recognizing the Brugada ECG pattern is the foundation stone to assist patients and avoid misconceptions.

This book, Brugada Phenocopy: The Art of Recognizing the Brugada ECG Pattern, provides a straightforward and practical guide to analyze all aspects of this condition: including usual and unusual ECG presentations, sophisticated but easy ways to determine the presence of a Brugada ECG pattern and a systematic approach to differentiate true genetic Brugada syndrome from BrP.

I welcome all of you to read this book and discover the fascinating world of electrocardiology. The ECG remains alive as a productive, inexpensive, and everyday medical diagnostic tool.

Adrian Baranchuk

Kingston, ON,