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Discussion of type 1 Brugada electrocardiogram in patients with pulmonary embolism.

We read with interest the case presentation by Ghatak et al, because we have also experienced similar electrocardiogram (ECG) cases with massive pulmonary embolism (1, 2). Although the authors discussed the etiology of these ST-segment elevations, they did not mention the characteristic ST-segment elevation in the right precordial lead, which is similar to type 1 Brugada ECG patterns. We agree with the authors the plausibility of attributing the ECG findings to right ventricular ischemia secondary to pulmonary embolism.

Brugada syndrome is a well-known inherited syndrome characterized by Brugada ECG patterns in precordial leads V1 to V3 that can predispose individuals to ventricular arrhythmias and sudden cardiac death. Some drugs and conditions can induce a Brugada type 1 ECG pattern in the absence of true congenital Brugada syndrome (3). Fever is one of the important factors to unmask the true congenital Brugada syndrome (4).

After Riera et al (5) introduced the term "Brugadaphenocopy" to describe acquired Brugada-like ECG manifestations, Baranchuk et al (6) clearly defined the term. Brugadaphenocopy type 1 class B is one of the possible differential diagnoses of the case. The accuracy and the importance of these diagnostic categories are still unknown. We should wait for the results of their international registry. In cases of Brugadaphenocopy associated with acute pulmonary embolism, patients frequently present with shock and hypotension (7). To differentiate between true Brugada syndrome and Brugadaphenocopy, provocative challenge testing with a sodium channel blocker is theoretically needed. However, under shock and some other conditions, it is natural not to consider a challenge test.

Atsushi mizuno, MD, and Koichiro Niwa, MD

Department of Cardiology, St. Luke's International Hospital Tokyo, Japan


(1.) Ghatak A, Alsulaimi A, Acosta YM, Ferreira A. Acute pulmonary embolism masquerading as acute myocardial infarction. Proc (Bayl Univ Med Cent) 2015;28(1):69-70.

(2.) Yamagami F, Mizuno A, Shirai T, Niwa K. A savage sequence: ST-segment elevations with pulmonary embolism. Am J Med 2014;127(9): 820-822.

(3.) Bayes de Luna A, Brugada J, Baranchuk A, Borggrefe M, Breithardt G, Goldwasser D, Lambiase P, Riera AP, Garcia-Niebla J, Pastore C, Oreto G, McKenna W, Zareba W, Brugada R, Brugada P. Current electrocardiographic criteria for diagnosis of Brugada pattern: a consensus report. J Electrocardiol 2012;45(5):433-442.

(4.) Adler A, Topaz G, Heller K, Zeltser D, Ohayon T, Rozovski U, Halkin A, Rosso R, Ben-Shachar S, Antzelevitch C, Viskin S. Fever-induced Brugada pattern: how common is it and what does it mean? Heart Rhythm 2013;10(9):1375-1382.

(5.) Riera AR, Uchida AH, Schapachnik E, Dubner S, Filho CF, Ferreira C. Propofol infusion syndrome and Brugada syndrome electrocardiographic phenocopy. Cardiol J 2010;17(2):130-135.

(6.) Baranchuk A, Nguyen T, Ryu MH, Femeni'a F, Zareba W, Wilde AA, Shimizu W, Brugada P, Perez-Riera AR. Brugada phenocopy: new terminology and proposed classification. Ann Noninvasive Electrocardiol 2012;17(4):299-314.

(7.) Zhan ZQ, Wang CQ, Nikus KC, Perez-Riera AR, Baranchuk A. Brugada phenocopy in acute pulmonary embolism. J Cardiol 2014;177(3):e153-e155.

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Title Annotation:Reader comments
Author:Mizuno, Atsushi; Niwa, Koichiro
Publication:Baylor University Medical Center Proceedings
Article Type:Report
Date:Oct 1, 2015
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