ECG of the Week – 22nd May 2019 – Interpretation

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The ECG below is taken from an 83 year old man with a seizure history for the past 8 years. He presents after two 10 minute generalised tonic-conic seizures at home 10 days after self ceasing his Carbamazepine. He has a background history of HTN and has a PPM.

Click to enlarge

Answers

Interpretation – 

  • Rate: 78
  • Rhythm: NSR
  • Axis: Normal
  • Morphology: V1/V2 – Coved STE of 3mm/2mm respectively with TWI,     V3-Saddleback STE 2mm with TWI, Infrlat leads – around 1mm sagging STD.
  • Intervals: PR 120ms, QRS 120ms, QTC 445ms
  • Summary: Brugada Type 1 Pattern Changes

Brugada ECG –

3 types of change are described, although only one is diagnostic. The others require further testing with a sodium channel blocker used to unmask Type 1 change.

  • Type 1: (as above) Coved STE>2mm in more than one of leads V1-V3.
  • Type 2: Saddleback STE>2mm in same leads.
  • Type 3: Either coved or saddleback change of less than <2mm in same leads.
  • (please see links below for examples of these changes)

Brugada Syndrome –

Brugada syndrome is due to a result of a genetic mutation (most commonly – up to 30% – in the cardiac sodium channels) with a structurally normal heart and a risk for sudden cardiac death.

To be diagnosed with brugada syndrome you must also have at least one of the following clinical features:

  • Documented VF or VT
  • Family history of sudden cardiac death
  • Familial history of same ECG changes
  • History of syncope
  • Nocturnal agonal respiration.

Most frequently seen in men (and higher in those of Asian descent) in the age 20-55.

Clinical Relevance – 

Carbamezipine acts on myocardial Na channels as well as those in the brain and is associated with Brugada like ECG changes (although the exact pathophysiology is not fully understood)

Interestingly it is unknown whether there is the same risk of death in drug induced Brugada type change.

Brief dysrhythmia could have mimicked seizure type activity in this case (in terms of clinical closure this gentleman had a normal CTB and had only developed seizures in late life)

References / Further Reading – 

Textbook:

Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

Studies:

Sudden cardiac death is associated both with epilepsy and with use of antiepilpetic medications. Bardai A, et al. Heart 2015

(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5725848/)

Online:

https://lifeinthefastlane.com/what-is-brugada-syndrome/