Brugada Syndrome: Diagnostic Pitfalls

The effect of precordial lead displacement on ECG morphology

“…It was already shown that shifts of precordial leads by 2 cm can result in altered R wave progression and shift in the precordial transition zone, respectively, in 20 and 75 % of patients [9] as well as altered QRS complex and T wave [12] leading to misinterpretation regarding anteroseptal infarction and ventricular hypertrophy [9], or false statements about appearance of myocardial ischemia or right bundle branch block [12]. The analysis of ECG signals recorded from vertically displaced V 1 and V 2 leads could also give false impression of Brugada syndrome [16]. Schijvenaars et al [26, 28] studied the relation of horizontal simultaneous displacement of V 1 –V 3 leads on the changes of computer-based diagnosis concerning MI and left ventricular hypertrophy (LVH).…”

“…The analysis of ECG signals recorded from misplaced electrodes can lead to misinterpretation or even to significant diagnostic errors like incorrect recognition of anterior infarction, anteroseptal infarction, ventricular hypertrophy [9, 14], false diagnosis of ischemia, or Brugada syndrome [16, 24]. Bond et al have shown that incorrect electrode placement could lead to wrong diagnosis in 17–24 % of patients [1].…”

ICD Implantation and Evidence-Based Patient Selection

“…3 Practice guidelines are an important starting point for clinical decision making, but they are not a substitute for clinical judgment, which can provide independent value. 4 The National Cardiovascular Data Registry (NCDR) ICD Registry analyzed by the authors is not designed to determine the medical necessity of ICD implants that do not meet evidence-based guidelines.…”

“…Lack of familiarity with the rigor that such ascertainment entails can lead to overdiagnosis 3,4 that, in turn, may prompt ICD therapy. [3][4][5] Thus, characterization of the full extent of inappropriate ICD implantations will likely necessitate broadening the scope of investigation initiated by Al-Khatib et al to include the problem of false-positive identification of "guideline-approved" ICD candidates. Correction of the problem may require enhanced quality control strategies for ejection fraction quantitation methods as well as improved training and continuing education of physicians.…”

Proposed Bedside Maneuver to Facilitate Accurate Anatomic Orientation for Correct Positioning of ECG Precordial Leads V1 and V2: A Pilot Study

“…Yet, despite standardization of their locations since the late 1930s, precordial leads V1 through V6 are still often subject to erroneous and inconsistent placement on the chest (1,(3)(4)(5)(6)(7)(8)(9)(10)(11)(12). Such lapses in procedural adherence can lead not only to altered R-wave amplitude, but also false ECG diagnoses, most significantly ''ischemia'' (T-wave inversion, or ST-segment shifts) and ''infarction'' (Q waves or QS complexes), and additionally, ''Brugada syndrome'' (5,8,(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23). These misdiagnoses are far from trivial in that they can prolong evaluation time in the emergency department (ED) (and, thereby, contribute to the crowding problem); cause postponement of previously scheduled surgical procedures; lead to unnecessary non-invasive (and perhaps even invasive) diagnostic cardiac tests; prompt treatments that are potentially risky (e.g., intravenous antithrombotic or antiplatelet therapy) or expensive; and possibly raise a red flag if the patient applies for employment or life insurance (22,24).…”