Workup for Suspected Brugada Syndrome: Two Case Reports for the General Practitioner

Abstract

While a large proportion of ST-segment elevation on EKG is related to myocardial ischemia, the differential diagnosis must include pericarditis, channelopathies, and various genetic conditions. Identifying and working up such abnormalities present a challenge to primary care providers (PCPs). We present two clinical cases of young male patients with ST-segment elevation in anteroseptal leads suspicious for Brugada syndrome and show how to risk stratify and manage them.Our first case presents a 23-year-old male with no past medical history with acute onset substernal chest pain, shortness of breath, and palpitations. Initial workup revealed negative serial troponins and normal Btype natriuretic peptide (BNP). The EKG revealed ST elevation in lead V2. An evaluation for Brugada syndrome was pursued. Upon completion of a procainamide challenge, it was determined that he did not have Brugada syndrome and was shortly discharged.Our second case presents a 33-year-old male with no pertinent cardiac medical history who presented to an outpatient cardiology clinic after discovering an incidental ST elevation in V2 on EKG. His family history was negative for early atherosclerotic cardiovascular events or sudden cardiac death. The patient's initial workup was negative. Suspicion for Brugada syndrome leads to performing a procainamide challenge, which was significant for ST changes in the anterolateral leads. He was asymptomatic during the challenge and initial presentation, and no further intervention was indicated. He was advised to avoid sodium channel blocking medications and treat any fevers and was sent for genetic testing.These cases illustrate the importance of maintaining an appropriate suspicion for Brugada syndrome in young patients with minimal ischemic risk factors. We discuss a guideline-directed algorithmic workup for PCPs in suspicious individuals. Stratifying patients based on the presence of symptoms, history of tachyarrhythmias, and EKG findings before and after drug challenge allows physicians to guide further management of these patients.

A Case of Brugada Syndrome Masquerading as Acute Coronary Syndrome in a Hispanic Male

“…Brugada syndrome diagnosis can be challenging, as it often requires a combination of clinical, electrocardiographic, and genetic evaluations [2]. The differential diagnosis for ST-T changes in right precordial leads includes anteroseptal ischemia, right bundle branch block, early repolarization syndrome, arrhythmogenic right ventricular cardiomyopathy, various substance abuse, and electrolyte abnormalities [5][6][7][8]. Structural heart disease must be ruled out in every case.…”

“…However, subsequent EKG showed that the patient had a type I Brugada pattern, considered a more severe condition. The change from type II to type I pattern on EKG highlights the dynamic and evolving nature of Brugada syndrome and the importance of continuous monitoring and assessment [6].…”