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Brugada ECG Patterns

 

Types of brugada on ecg


Brugada ECG Patterns: A Comprehensive, Clinically Oriented Guide

Overview

Brugada syndrome is an inherited cardiac ion-channel disorder characterized by distinctive ECG patterns in the right precordial leads and an increased risk of malignant ventricular arrhythmias and sudden cardiac death (SCD), often in structurally normal hearts. The ECG phenotype is dynamic and may be concealed, unmasked, or modulated by fever, drugs, and autonomic tone.



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ECG Patterns of Brugada Syndrome


Type 1 (Diagnostic Pattern)


Key features


Coved ST-segment elevation ≥2 mm in ≥1 right precordial lead (V1–V3)


Followed by a negative T wave


J-point elevation with downsloping ST segment



Clinical significance


Only ECG pattern diagnostic of Brugada syndrome (when present spontaneously or induced by sodium-channel blocker)


High arrhythmic risk, especially if spontaneous and associated with symptoms




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Type 2 (Suggestive Pattern)


Key features


Saddleback ST elevation ≥2 mm


ST segment remains elevated ≥1 mm


Positive or biphasic T wave



Clinical significance


Not diagnostic


Requires further evaluation (lead repositioning, drug challenge)




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Type 3 (Suggestive Pattern)


Key features


Saddleback or coved morphology


ST elevation <2 mm



Clinical significance


Lowest specificity


Common in normal individuals




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Lead Placement Matters


Place V1 and V2 one or two intercostal spaces higher (2nd or 3rd ICS) to enhance sensitivity


High right precordial leads can convert type 2/3 to diagnostic type 1




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Dynamic Nature of the ECG


Brugada ECG patterns can be intermittent and influenced by:


Fever (most important reversible trigger)


Sodium-channel–blocking drugs (Class I antiarrhythmics, certain psychotropics)


Alcohol


Electrolyte disturbances


Increased vagal tone (rest, sleep)




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Diagnostic Criteria


Diagnosis requires:


Type 1 ECG pattern (spontaneous or drug-induced) Plus at least one of the following (for clinical diagnosis):


Documented ventricular fibrillation (VF) or polymorphic VT


Syncope of arrhythmic origin


Family history of SCD <45 years


Type 1 ECG in a first-degree relative


Inducible VT/VF on programmed stimulation (controversial)




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Differential Diagnosis of Right Precordial ST Elevation


Acute anterior or anteroseptal STEMI


Right ventricular hypertrophy


Early repolarization


Arrhythmogenic right ventricular cardiomyopathy (ARVC)


Acute pericarditis


Hyperkalemia


Pulmonary embolism




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Risk Stratification


High-risk features


Previous cardiac arrest or documented VF


Arrhythmic syncope


Spontaneous type 1 ECG


Male sex


Fragmented QRS, short ventricular refractory periods (supportive markers)



Lower-risk


Asymptomatic individuals with drug-induced type 1 ECG




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Management of Brugada Syndrome


1. General Measures (For All Patients)


Aggressive fever management (paracetamol, early treatment)


Avoid contraindicated drugs (updated lists on BrugadaDrugs.org)


Avoid excessive alcohol


Prompt treatment of electrolyte abnormalities




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2. Implantable Cardioverter-Defibrillator (ICD)


Indications


Survivors of cardiac arrest (Class I)


Documented spontaneous sustained VT/VF


Syncope with spontaneous type 1 ECG and high suspicion of arrhythmia



Not routinely recommended


Asymptomatic patients with only drug-induced type 1 ECG




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3. Pharmacological Therapy


Quinidine


Reduces Ito current, stabilizes epicardial action potential


Useful for:


Recurrent ICD shocks


Patients refusing or unsuitable for ICD


Electrical storms




Isoproterenol (IV)


Acute management of electrical storm


Especially effective in VF storms




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4. Catheter Ablation


Targeting arrhythmogenic substrate in the right ventricular outflow tract (RVOT)


Considered in:


Recurrent VF


Frequent ICD shocks despite medical therapy





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Special Situations


Fever-Induced Type 1 ECG


Treat fever aggressively


Hospital monitoring if type 1 pattern appears during fever


Counsel patients and families



Asymptomatic Patients


No ICD routinely


Close follow-up


Lifestyle and drug avoidance counseling



Family Screening


ECG screening of first-degree relatives


Consider genetic testing (SCN5A and others), though yield is modest




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Key Take-Home Points


Type 1 Brugada ECG is diagnostic


Type 2 and 3 are suggestive only


ECG pattern is dynamic and may require provocation


Fever is a major, preventable trigger


ICD remains the cornerstone of therapy for high-risk patients


Quinidine and ablation are important adjuncts in selected cases


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