A Rare yet Morbid Complication of Cocaine Use: Brugada Type 1 on Electrocardiogram

Abstract

Cocaine is considered a leading non-opioid cause of drug overdose in the US. It acts as a sympathomimetic and increases the amount of catecholamines, thereby increasing the risk of ventricular irritability and resultant arrhythmias. Its sodium (Na) channel blockage is the principal mechanism behind the Brugada pattern on an electrocardiogram (ECG), which is often transient but is indistinguishable from that of Brugada syndrome, the autosomal dominant channelopathy.We are presenting a case of a 32-year-old male with a history of cocaine and nicotine abuse, who sought medical attention for sudden-onset palpitations and pressure-like chest pain after having snorted an impressive amount of cocaine. His ECG depicted a classical Brugada pattern with ST-elevation with T inversion in V1; however, previous ECGs were normal without ST changes, signifying the Brugada pattern unmasked by cocaine use. Other investigations including stress tests and nuclear imaging were equivocal. His symptoms as well as the ECG pattern reverted to baseline signifying the presence of Brugada phenotype in the absence of channelopathy.Hence, as a sodium channel blocker, cocaine may unmask latent Brugada syndrome in asymptomatic patients without a family history. Recognizing Brugada syndrome on ECG is vital to avoid misdiagnosis and mistreatment of the patient with and without a genetic predisposition.

Brugada Phenotype Following a Cocaine Overdose

“…In Brugada syndrome, findings associated with a loss-of-function mutation in the SCN5A gene reveal alterations in the encoding of alpha subunits of myocardial sodium channels. These genetic defects result in defective sodium channels that decrease sodium influx while enhancing outward current, thereby leading to a plateaued action potential and increasing susceptibility to reentry ventricular arrhythmias [ 4 , 5 ]. Cocaine is a known cardiac sodium channel blocker and inhibits these channels by preferentially binding to open or inactivated states, inducing concentration-dependent inhibition and slowing channel repriming, suggesting a pore-blocking mechanism and stabilization of the channels in an inactivated state [ 6 ].…”

“…Cocaine is a known cardiac sodium channel blocker and inhibits these channels by preferentially binding to open or inactivated states, inducing concentration-dependent inhibition and slowing channel repriming, suggesting a pore-blocking mechanism and stabilization of the channels in an inactivated state [ 6 ]. Therefore, we predict that in a mechanism similar to that of the loss of function mutation within the SCN5A gene, cocaine may either directly produce Brugada-like ECG findings or may actually serve to unmask underlying Brugada syndrome in otherwise asymptomatic patients through the decreased cardiac sodium influx [ 4 ].…”

“…Comprehensive investigations are needed to understand the potential reversibility of these cocaine-induced alterations and their clinical significance. At this time, cocaine has no approved antidote in case of overdoses, so patients with cocaine-related Brugada-like ECG patterns should be treated with standard supportive therapy, which may include nitroglycerin, benzodiazepines, and electrolyte management [ 4 ]. Active cooling and sodium bicarbonate infusions have also been found to help normalize blood pH in cocaine overdose and help reverse cardiac conduction issues [ 18 ].…”

“…Cocaine has been linked with Brugada syndrome in a few case studies to date. In a previous case report following the prognosis of a 32-year-old male with a history of cocaine and nicotine abuse presenting with a Brugada ECG pattern unmasked by cocaine use, the authors propose that cocaine's sympathomimetic effects and sodium channel blocking properties can induce transient Brugada-like patterns in individuals without a genetic predisposition to Brugada syndrome [ 4 ]. These patterns, observed after cocaine use, highlight the importance of distinguishing drug-induced ECG changes from genuine Brugada syndrome to ensure appropriate management.…”

“…These patterns, observed after cocaine use, highlight the importance of distinguishing drug-induced ECG changes from genuine Brugada syndrome to ensure appropriate management. While treatments for cocaine-related cardiac complications exist, the long-term consequences and outcomes of drug-induced Brugada-like patterns remain uncertain [ 4 ].…”