A 12-lead ECG STEMI Mimic: The Brugada Syndrome

Copyright 2023 ECGcourse.com LLC. All rights reserved. | Vernon R Stanley, MD, PhD Author | Courtney Stanley, PA-C | Special thanks to Thomas J. DeVito, MS, PA-C for contributing the original patient presentation. Tom is a cardiology PA, a content reviewer for ECGcourse.com and a former student of Dr. Stanley.

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Please answer the following questions regarding 12-lead ECG STEMI Mimics & Classic characteristics of the Brugada Syndrome

1. True or False: The Brugada Syndrome is a benign aberrancy on the 12-lead Lead ECG and for the most part can be ignored.
   • True
   • False
2. The Hallmark on the 12-lead ECG of Brugada Syndrome is a ramp-like ST elevation of approximately:
   • 15 degrees
   • 45 degrees
   • 85 degrees
   • None of the Above
3. The Brugada Syndrome on the 12-lead ECG can be commonly misdiagnosed as:
   • A. Right Bundle Branch Block
   • B. ST Elevation MI (STEMI)
   • C. Ventricular Tachycardia
   • D. A & B Only
   • E. None of the Above.

Answer key below blog post.

 (C) 2023 | Vernon R. Stanley, MD PhD. All rights reserved.

Case Study

Patient presentation: You are working with a missionary medical team in an outpatient clinic in Northeast Thailand.  The 51-year-old male below presents with complaints of recurring syncopal episodes. Your interpretation/recommendation for the 12-lead ECG tracing below would be as follows:

This 12-lead ECG case study is a classic example of the Brugada Syndrome. You can easily see from the tracing below why one might interpret the 12-lead ECG as one of an acute ST-elevation MI or STEMI (Anteroseptal region). Note particularly, the ST-segment elevation and T-wave inversion in Lead V3 of the 12-lead ECG above.

Brugada Syndrome is a cardiac abnormality and genetic disorder (autosomal dominant transmission). It is characterized by an electrical abnormality visible on the 12-lead ECG tracing with a structurally normal heart. The syndrome proper is characterized as follows (without symptoms it is referred to as the Brugada Sign):

1. Clinical episodes of near syncope, syncopal episodes, seizures or sudden death.
2. Structurally normal heart.
3. Characteristic 12-lead ECG pattern displaying ST elevation and T-wave inversion/biphasic T’s in Leads V₁, V₂ and V₃. The Brugada pattern resembles Right Bundle Branch Block (RBBB).

The Incidence of Brugada Syndrome

Brugada Syndrome has been recognized virtually worldwide, less common in the United States and most common in southeast Asia (Thailand and Laos). It is stated to be responsible for five deaths per year per 10,000 population in areas where it is endemic. The arrhythmia leading to sudden death is Polymorphic Ventricular Tachycardia (also known as Torsades de Pointes) with degeneration to ventricular fibrillation.

12-lead ECG Characteristic of the Brugada Syndrome
For emphasis, I have magnified Lead V₂. Please note that the ST-segment on this 12-lead ECG has been labeled and color-coded pink. The ST segment assumes a peculiar ramp-like elevation at an angle of nearly 45 degrees. The T-wave is inverted (negative). These ST-T changes are the hallmark of the Brugada Syndrome.

Common misdiagnosis of the Brugada Tracing
A careful analysis of the 12-lead ECG tracing above will reveal why Brugada Syndrome is frequently misdiagnosed as the following:
A.  Atypical Right Bundle Branch Block (RBBB): This 12-lead ECG tracing demonstrates RSR’ in Lead V₂ with a biphasic Lead I and small terminal S-wave. The QRS duration is slightly prolonged. These changes might necessarily imitate RBBB.
B. Acute STEMI, particularly Acute Anteroseptal MI: ST elevation (concave down) in Leads V₁, V₂ and V₃ and T-wave inversion or biphasic T-waves in Leads V₁, V₂, and V₃.

Treatment of the Brugada Syndrome

If treatment is indicated, please know that the objective would be directed to the prevention of Ventricular Tachycardia and sudden death. Some patients with 12-lead ECG changes of Brugada Sign might be negative for sudden death and the patient’s history might be negative for syncope, pre-syncope or seizures. However, ALL patients you encounter in your practice with these classic Brugada ECG findings should be referred to the cardiologist for a work-up and treatment recommendation (choose a cardiologist who has a familiarity with this disorder).

If the Brugada Syndrome patient is experiencing symptoms related to transient Ventricular Tachycardia, antiarrhythmic drugs including beta blockers and amiodarone, are ineffective to prevent Ventricular Tachycardia and sudden death. The only effective treatment mode is the automatic implantable defibrillator.

Additional information regarding the Brugada Syndrome

1. Brugada Syndrome is characterized by ST-segment elevation in ECG Leads V₁, V₂, V₃ with a peculiar slant at approximately 45 degrees and T-wave inversion or biphasic T-waves.
2. The disorder occurs worldwide but is most common in Southeast Asia.
3. The QT interval on the 12-lead ECG is usually normal (<1/2 R-R)
4. The only treatment for Brugada Syndrome to avoid Ventricular Tachycardia, Ventricular Fibrillation and sudden death is the automatic implantable defibrillator.
5. Incidence of the Brugada Syndrome male to female is approximately 8:1.
6. Death commonly occurs during rest or sleep (in Thailand, it is known as “lai tai” [“death during sleep”]).
7. Brugada Syndrome is a genetic disorder.
8. Medications such as amiodarone or beta blockers do NOT prevent sudden death for patients with Brugada.
9. With no known history of cardiac disease, Brugada Syndrome is the most common cause of sudden death age < 50 years in South Asia.
10. Brugada Syndrome may be the leading cause of natural death among young men in poverty-stricken Northeast Thailand.

Answer Key

1. True or False: The Brugada Syndrome is a benign aberrancy on the 12-lead Lead ECG and for the most part can be ignored.

• True
• False

2. The Hallmark on the 12-lead ECG of Brugada Syndrome is a ramp-like ST elevation of approximately:

• 15 degrees
• 45 degrees
• 85 degrees
• None of the Above

3. The Brugada Syndrome on the 12-lead ECG can be commonly misdiagnosed as:

• A. Right Bundle Branch Block
• B. ST Elevation MI (STEMI)
• C. Ventricular Tachycardia
• D. A & B Only
• E. None of the Above.

Additional Reading

• Brugada Syndrome • LITFL • ECG Library Diagnosis
• Brugada syndrome – Symptoms & causes – Mayo Clinic
• Clinical Trials on Brugada Syndrome – Clinical Trials Registry – ICH GCP
• Brugada Syndrome: Symptoms & Treatment (clevelandclinic.org)

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