Induced Brugada-Type Electrocardiogram, a Sign for Imminent Malignant Arrhythmias

Junttila, M. Juhani; Gonzalez, Maday; Lizotte, Éric; Benito, Begoña; Vernooy, Kevin; Sarkozy, Andrea; Huikuri, Heikki V.; Brugada, Pedro; Brugada, Josép; Brugada, Ramón

doi:10.1161/circulationaha.107.746495

Cited by 149 publications

(115 citation statements)

References 11 publications

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“…Patients may have a normal baseline ECG with induction of the abnormality with drugs or medications with sodium channel blocking properties. The unmasking of the Brugada pattern (often provoked with agents such as cocaine, propofol, tricyclic antidepressants, anesthetics, antiarrhythmic medications, as well as fever or electrolyte imbalance) has been highly-associated with risk for malignant arrhythmias and cardiac arrest [13]. The appearance of a Brugada pattern has been reported in the context of opiate use, such as methadone ingestion and tramadol overdose in previously-published cases [14,15].…”

Section: Discussionmentioning

confidence: 99%

Conduction Disturbances and Ventricular Arrhythmias Associated with High- Dose Loperamide

Leung

Altshuler²,

Goldenberg³

et al. 2016

J Clinic Toxicol

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Although loperamide has been widely used for the treatment of diarrhea, there is growing popularity over its abuse potential in alleviating opioid-withdrawal symptoms and achieving euphoria. Toxic levels of loperamide have been associated with life-threatening ventricular tachyarrhythmias and cardiac arrest. We report a case of high-dose loperamide ingestion in a patient presenting initially with unstable bradycardia followed by episodes of polymorphic ventricular tachycardia, and an unmasked Brugada ECG pattern. This is the first such report of the Brugada pattern being unmasked on ECG with loperamide ingestion. The patient stabilized with supportive care without the need for inotropic support. We discuss potential mechanisms of toxicity leading to conduction abnormalities and provide a literature review of all published cases of loperamide toxicity to describe proposed treatment options. Recognition of the abuse potential and hazards of this over-the-counter anti-diarrheal therapy will alert the clinician of associated toxidromes and management strategies.

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Section: Discussionmentioning

confidence: 99%

Conduction Disturbances and Ventricular Arrhythmias Associated with High- Dose Loperamide

Leung

Altshuler²,

Goldenberg³

et al. 2016

J Clinic Toxicol

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“…Bu olgularda hem genel anestezi hem de rejyonal anestezi uygulanabilmektedir. Ancak literatürde, kullanılan ilaçların malign aritmileri tetikleyebildiği; özellikle propofol, lidokain ve bupivakainin bu konuda dikkat edilmesi gereken ilaçlar olduğu bildirilmektedir (6). Rejyonal anestezinin sorunsuz uygulandığı BS olguları olduğu gibi, rejyonal anestezi sırasında Brugada benzeri EKG şeklinin gözlendiği olgular da literatürde mevcuttur (7,8).…”

Section: Discussionunclassified

Sugammadex in a Patient with Brugada Syndrome

Biricik¹,

Hatipoğlu²,

Küçükbingöz³

2016

Turk J Anaesth Reanim

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Brugada Sendromu ilk kez 1992 yılında Pedro Brugada tarafından tanımlanan, ani kalp durması ile sonuçlanabilen ventrikül aritmileri ile karakterize genetik bir sendromdur. Bu sendromda özel-likle sağ dal bloğu ve sağ prekordiyal derivasyonlarda ST segment elevasyonu gözlenmektedir. Perioperatif birçok farmakolojik ve fizyolojik faktör bu malign aritmileri tetikleyebilir. Nadir görülen bir durum olmasına rağmen ölümcül komplikasyonlarla seyredebildiğinden Brugada Sendromunda anestezi uygulaması önem arz etmektedir. Brugada sendromlu hastaların ameliyatlarında birçok anestezi ilacı uygulanmıştır. Bu makalede sugammadeks kullanı-mının genel anestezi uygulanan Brugada sendromlu hastadaki yeri tartışıldı.Anahtar kelimeler: Brugada Sendromu, sugammadeks, anestezi Brugada Syndrome was first described in1992 by Pedro Brugada as a genetic syndrome that is characterized by ventricular arrhythmias that may result in sudden cardiac arrest. In particular, a right bundle branch block and ST segment elevation in the right precordial leads are observed. Many perioperative pharmalogical and physiological factors can trigger malignant arrhythmias. Although it is a rare condition, the anaesthestic management of Brugada syndrome is important because of the potentially fatal complications. Many anaesthetics have been administered during the operation of patients with Brugada Syndrome. The use of sugammadex instead of the anaesthetic management of patients with Brugada syndrome is discussed in this study. Keywords Giriş Brugada Sendromu (BS) nadir görülen bir sendrom olmasına rağmen, ventrikül taşikardisi ve fibrilasyonu gibi malign aritmilere neden olabileceğinden anestezistler için dikkat edilmesi gereken bir klinik tablodur (1). Kalbin iletim sistemindeki iyon kanallarını etkileyerek sağ prekordiyal derivasyonlarda ST segment elevasyonu ve sağ dal bloğuna neden olan otozomal dominant bir hastalıktır (2). Özellikle sodyum kanallarında işlev kaybı kalbin aksiyon potansiyelinde dengesizliğe, dolayısıyla transmural voltaj farkına sebep olarak karakteristik ST segment elevasyonu oluşturmaktadır (3). İmplante edilebilir defibrilatör (ICD), Brugada sendromunda etkin tek tedavi olarak görülmektedir (4). Bu hastalar ICD yerleştirilmesi veya diğer cerrahi girişimler için anestezi uygulamasına ihtiyaç duyabilmektedirler. Olgu SunumuYirmi altı yaşında, multipar (üçüncü gebelik), BS tanılı olgu aktif travay nedeniyle acil şartlarda sezaryen (C/S) ameliyatına alındı. Özgeçmişinde, bir yıl önce ara ara oluşan yaklaşık 5 dakika süren, istirahat ile geçen göğüs ağrısı ve baş dönmesi tarif ediyor. Bu nedenle kardiyoloji kliniğine başvurduğunda tetkikler sonucunda Brugada Sendromu tanısı konuluyor ve ICD yerleştiriliyor. Tanı öncesinde geçirilmiş iki C/S girişimi olan olgunun aile anamnezinde, nedeni bilinmeyen ani iki kardeş ölümü ve baba ile erkek kardeşte kalp hastalığı öyküsü mevcuttu. Laboratuar incelemesinde hemogram ve elektrolit düzeyleri normal olan olgunun EKG'de sağ dal bloğu ve aVR, aVL ve V 1 -V 3 derivasyonlarında ST segment elevasyon...

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“…Several cases similar to the one described here have been shown to be triggered by fever. One study showed that such patients are at a very high risk of developing malignant ventricular tachycardia during the same acute event that triggered the Brugada pattern ECG changes [8]. With this mode of presentation that can be fatal, it is imperative that such patients are treated for fever or taken off the offending medication as soon as a Brugada pattern is identifi ed.…”

Section: Dear Editormentioning

confidence: 99%

“…There are two distinctly described ECG patterns, type I Brugada is characterized by ST elevation (≥2mm) with a "coved" pattern or a T-wave which is inverted with an upward convexity, in other cases the elevated ST segment descends and rises again forming a "saddleback" type pattern, this is called the type II Brugada. The electrophysiological and clinical manifestations of this syndrome have been found to be secondary to various factors [3][4][5][6][7][8][9][10]. Of these, mutations in cardiac sodium channel SCN genes (SCN5A and SCN10A) are the most well-known [11].…”

mentioning

confidence: 99%

Fever Induced Brugada Syndrome

Munshi¹

2017

Ann Circ

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Brugada syndrome is a heterogeneous genetic channelopathy that predisposes to ventricular arrhythmias and sudden cardiac death (SCD). The electrocardiogram (ECG) fi ndings only suggest a diagnosis of Brugada syndrome but are not confi rmatory. The ECG pattern is known to vary with time in some patients and many have a normal baseline ECG [1,2]. There are two distinctly described ECG patterns, type I Brugada is characterized by ST elevation (≥2mm) with a "coved" pattern or a T-wave which is inverted with an upward convexity, in other cases the elevated ST segment descends and rises again forming a "saddleback" type pattern, this is called the type II Brugada. The electrophysiological and clinical manifestations of this syndrome have been found to be secondary to various factors [3][4][5][6][7][8][9][10]. Of these, mutations in cardiac sodium channel SCN genes (SCN5A and SCN10A) are the most well-known [11]. Since all affected families do not have these mutations, it is believed that other mutations in sodium channel genes or mutations in non-sodium channel genes may also cause Brugada syndrome [12][13][14][15].There have been some cases with a normal baseline EKG where in a Brugada pattern was induced by factors such fever, infection, cocaine use and even medication, particularly sodium channel blocking agents. With SCD being a common presenting symptom, it is critical to make an early diagnosis and institute preventive treatment such as an implantable cardioverter defi brillator. Our case described below is of a patient who presented to the emergency room (ER) with a fever and was found to have a pattern of ST elevation without any other cardiac symptoms.The patient is a 71 year old male who presented to the emergency room with fever (103.5 F). An ER ECG ( Figure 1) showed RBBB, coved ST elevation in leads V1-V4 with T-inversion characteristic of Type I Brugada syndrome. He was urgently taken for left heart catheterization, which revealed normal coronaries. An echocardiogram performed two days after this showed normal left and right ventricular function.His EKG went back to his baseline pattern of RBBB/LAFB after fever resolution (Figure 2) and a diagnosis of type I Brugada syndrome unmasked in the setting of fever was made. He was offered defi brillator implantation, but he opted for conservative management.Upon asking for a prior history of syncope, he reported two events; one when he was seventeen and another in his thirties.Both times he was in a hot environment and experienced a prodrome of feeling confi ned and crowded before briefl y losing consciousness, suggestive of a vasovagal etiology and did not seek medical attention at the time.Brugada syndrome triggered by fever is known to predispose to malignant ventricular arrhythmias. Other factors

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Induced Brugada-Type Electrocardiogram, a Sign for Imminent Malignant Arrhythmias

Cited by 149 publications

References 11 publications

Conduction Disturbances and Ventricular Arrhythmias Associated with High- Dose Loperamide

Conduction Disturbances and Ventricular Arrhythmias Associated with High- Dose Loperamide

Sugammadex in a Patient with Brugada Syndrome

Fever Induced Brugada Syndrome

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