EKG of the Week 2019 1-6

This EKG comes courtesy of Dr. Ann Giovanni.

A 63 year old male, with a history of HTN and DM, was teaching computer class when he had a syncopal episode. EMS was called and he had a second syncopal episode while on the EMS monitor. The rhythm strip is below.

2019 1-6 EMS strip.JPG

He woke up on his own prior to being shocked by EMS. He arrived in the ED with no chest pain and no shortness of breath but feeling like he was going to pass out.

His ED EKG is below.

2019 1-6.jpg

1.    What does the EKG demonstrate?

2.    How would you manage this patient?

ANSWER:

The rhythm strip demonstrates ventricular fibrillation. The EKG shows downsloping ST segments in leads V1-V3 consistent with Brugada syndrome.

Patients with Brugada syndrome require placement of an ICD.

 

Evaluating patients after syncope can be challenging. In the absence of a clear history suggesting a particular cause (i.e. subarachnoid hemorrhage, pulmonary embolism), we are often left wondering whether the patient had a cardiac arrhythmia as the cause of their syncope or was it a more benign cause. The only way to know for sure is to have the patient on an EKG machine at the time of the syncope which usually doesn’t happen. Otherwise we are left with looking at an EKG taken after the syncope to see if it gives us clues that the patient may have had an arrhythmia as the cause of their syncope (i.e. prolonged QT, WPW, Brugada, ARVD).

In this case Dr. Giovanni’s team was fortunate that EMS had the patient on a monitor at the time of a syncopal episode and was able to capture the ventricular fibrillation. Now we know that the patient’s syncope was certainly due to a dangerous arrhythmia. The next question becomes why did the patient have spontaneous v-fib? The EKG gives us the answer.

The EKG demonstrates a sinus rhythm with a 1st degree AV block and PVC’s. There are also downsloping ST segments in leads V1-V3 leading into inverted T waves. There is no isoelectric separation between the QRS complex and the T wave. This is consistent with Brugada syndrome.

Brugada syndrome is a genetic (autosomal dominant) sodium channel defect. It predominantly affects males (90%). Patients with Brugada syndrome are at risk for ventricular arrhythmias such as polymorphic V-tach and v-fib. Patients who had a syncopal episode who have an EKG pattern consistent with Brugada syndrome likely had a ventricular arrhythmia. There is no specific treatment for Brugada syndrome. So, these patients require placement of an ICD to manage their ventricular arrhythmias.