Brugada Phenocopy: The Art of Recognizing the Brugada ECG Pattern
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About this ebook
Brugada Phenocopy: The Art of Recognizing the Brugada ECG Pattern details all aspects associated with alternative diagnosis to Brugada Syndrome (BrS). Coverage includes how to identify the proper ECG pattern, what to do to investigate for BrP, and how to avoid misinterpretations and the use of unnecessary and expensive treatments. Chapters are written by experienced professionals, many of whom are colleagues that initially described this condition. This easy to use volume is a must have reference for researchers of cardiology, cardiologists, electrocardiologists, internists, emergency care doctors and students, residents and fellows.
- Assists in the proper recognition of the Brugada ECG patterns and how to distinguish true BrS from other conditions with identical ECG
- Expands understanding on how to properly recognize the ECG of Brugada patterns
- Contains access to a companion website with video to enhance understanding of proper measurement of the beta angle (Chevallier) and the base of the triangle (Serra)
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Brugada Phenocopy - Adrian Baranchuk
Brugada Phenocopy
The Art of Recognizing the Brugada ECG Pattern
Adrian Baranchuk MD FACC FRCPC FCCS
Professor of Medicine (Tenure)
Queen's University
Kingston, Ontario, Canada
Editor-in-Chief, Journal of Electrocardiology President, International Society of Electrocardiology Vice
President (Canada), Interamerican Society of Cardiology (SIAC)
Table of Contents
Cover
Title page
Table of Contents
Copyright
List of Contributors
Foreword
Preface
Chapter 1: The History of the Brugada Phenocopy Concept
Abstract
Introduction
Brugada syndrome (BrS)—the first consensus
Brugada syndrome—the second consensus
Brugada syndrome—the third consensus
Brugada Phenocopy (BrP)
Chapter 2: Brugada Phenocopy: Definition, Diagnosis, and Differentiation From True Brugada Syndrome
Abstract
Introduction to Brugada phenocopy
Classifying BrP
Diagnosis of BrP and its differentiation from BrS
The future of Brugada phenocopy
Chapter 3: The Value of the Sodium Channel Blocker Test in Brugada Syndrome and Brugada Phenocopy
Abstract
Introduction
Sodium channel blockers and Brugada syndrome
Sodium channel blockers and Brugada phenocopy
Similarities and differences between Brugada syndrome and Brugada phenocopy
Acknowledgment
Chapter 4: How to Recognize a Brugada ECG Pattern: The Beta Angle
Abstract
Acronyms
Chapter 5: How to Recognize a Brugada ECG Pattern: The Base of the Triangle
Abstract
Introduction
The differential diagnosis of RSr’ in the absence of structural heart disease
Conclusions
Chapter 6: The Rsr′ Pattern in Leads V1-V2: Algorithm and Differential Diagnosis
Abstract
Introduction
Causes of r′ (R′) in the precordial leads (V1-V2)
Pathological patterns
Clinical approach for the differential diagnosis of RSr′ pattern in lead V1: a proposed algorithm [14,15]
The importance of r′ in lead V1 to differentiate supraventricular arrhythmias
Summary
Chapter 7: International Registry and Educational Portal on Brugada Phenocopies
Abstract
Introduction
International Registry website—Welcome Tour
International Registry—categories and classification system
International Registry—2017 update
Future directions
Chapter 8: Specific Brugada Phenocopies: Ischemia
Abstract
The role of ischemia in BrS and BrP
Chapter 9: Specific Brugada Phenocopies: Acute Pulmonary Embolism
Abstract
Introduction
ECG manifestations of BrP in acute pulmonary embolism
Typical cases
Pathophysiological changes in acute pulmonary embolism
ECG manifestations and the possible mechanisms in acute pulmonary embolism
ECG differences between the Brugada syndrome and BrP in acute pulmonary embolism
ECG differences between the BrP in acute pulmonary embolism and anterior myocardial infarction
Chapter 10: Specific Brugada Phenocopies: Electrolyte and Metabolic Disorders
Abstract
Introduction
Common pathophysiology
Potassium imbalance
Conclusions
Acknowledgment
Chapter 11: The ECG of the Athlete and the Differential Diagnosis With the Brugada ECG Pattern
Abstract
Background
Type 1 pattern in athletes
Type 2 pattern in athletes
Early repolarization
Diagnostic approach
Conclusions
Chapter 12: The Value of the Vectorcardiogram in Brugada Syndrome
Abstract
Introduction
Vectorcardiographic features in the Brugada syndrome
Horizontal plane
Right sagittal plane
Discussion
Conclusions
Chapter 13: Exceptional Brugada Phenocopies
Abstract
Introduction
Conclusions
Chapter 14: Differentiation Between Brugada Syndrome and Brugada Phenocopy ECG Patterns: Is It Possible?
Abstract
Introduction
Expert interpretation
Electrocardiographic criteria
Conclusions
Chapter 15: The Future Is Here: Experimental Models and Genetics in Brugada Phenocopy
Abstract
Introduction
Experimental model of Brugada Phenocopy
Chapter 16: The Journey of Describing a New ECG Phenomenon
Abstract
Introduction and historical events
The journey of describing a new ECG phenomenon
Final considerations
Index
Copyright
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
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ISBN: 978-0-12-811151-2
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List of Contributors
Bryce Alexander, Kingston General Hospital, Queen’s University, Kingston, ON, Canada
Pavel Antiperovitch, University of Western Ontario, London Health Sciences Centre, London, ON, Canada
Daniel D. Anselm, Libin Cardiovascular Institute of Alberta, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
Raimundo Barbosa-Barros, Coronary Center of the Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Brazil
Héctor Barajas-Martinez, Masonic Medical Research Laboratory, Utica, NY, United States
Adrian Baranchuk
Queen’s University, Kingston, ON, Canada
Kingston General Hospital, Queen’s University, Kingston, ON, Canada
Division of Cardiology, Queen’s University, Kingston, ON, Canada
Antoni Bayés de Luna, Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, Barcelona, Spain
David G. Benditt, University of Minnesota, Minneapolis, MN, United States
Eugene H. Chung, Frankel Cardiovascular Center, University of Michigan Medical School, Ann Arbor, MI, United States
Gregory Dendramis, Pietro Cosma Hospital, Camposampiero, Padova, Italy
Luis Alberto Escobar-Robledo, Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, Barcelona, Spain
Javier García-Niebla, Servicios Sanitarios Área de Salud de El Hierro, Valle del Golfo Health Center, Islas Canarias, Spain
Byron H. Gottschalk, London Health Sciences Centre, Western University, London, ON, Canada
Dan Hu, Masonic Medical Research Laboratory, Utica, NY, United States
Ankit Maheshwari, University of Minnesota, Minneapolis, MN, United States
Albert Massó van Roessel, Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, Barcelona, Spain
Andrés R. Pérez-Riera, Design of Studies and Scientific Writing Laboratory at the ABC School of Medicine, Santo André, Brazil
Pieter G. Postema, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
Guillem Serra, Catalan Institute of Cardiovascular Sciences, St. Pau Hospital, Barcelona, Spain
Shiva Sreenivasan, South West Acute Hospital, Western Health and Social Care Trust, Enniskillen, United Kingdom
Grace Xu, Queen’s University, Kingston, ON, Canada
Zhong-Qun Zhan, Shenzhen Guangming Central Hospital, Shenzhen City, China
Foreword
The value of telescopic learning and curiosity in research
Once upon a time, someone looked at the night sky and saw the moon. There was not only the Sun during the day, but there was the moon by night. That someone called her the Moon and hurried to tell it and show her to others next nights. Now many people in the village new about the existence of the Moon. In the next weeks to years all the inhabitants in the many villages of the island came to know about the Moon. And so went for a long time. It was like all knowledge about the night sky had been gathered. But some curious people started to look by night at the starry sky. There was more than The Moon. There were Stars. Later on, some of those who already knew about the Stars, and were curious, continued looking at the starry sky and discovered the Planets. Others looked longer and suggested that during the day the Sun, and by night the Moon, the Stars and the Planets moved around the island sky. Every new inhabitant of the island knew now about the Sun, the Moon, the Stars, and the Planets. Whether they were moving around the Earth or whether the Earth was actually turning around herself became an important point of discussion. But every child had just sucked as a sponge the knowledge of previous generations. The years that took to recognize the Moon were reduced now to milliseconds for a kid to recognize her. The same kid needs now a few hours to learn about the Stars, Planets, and the major principles of the Cosmos. This is what we can call telescopic learning; it is like every new student has a larger and larger telescope than his predecessors, making it easier and easier to see new details. Centuries of knowledge are absorbed at the speed of light. The progressively increasing capacity to absorb knowledge comes from this telescopic learning, which is also the basis for the progressive acceleration of the historical time. This progressive acceleration is also the cause of the progressive acceleration of knowledge. Telescopic learning is a fact about existing knowledge. The motor to new knowledge is something else: Curiosity, scientific curiosity.
What has all this to do with this book edited by Adrian Baranchuk? This book is about electrocardiography and vectorcardiography. The ECG having been successfully used now for more than 100 years, keeps on behaving as a fabulous source of information and research. Nobody knows exactly how many millions of ECGs are recorded daily. The large majority of physicians behave like the millions of people seeing the stars. Only a few look at them. The ones looking seriously recognize which stars they are, but that is all. Only a few have the necessary curiosity to keep on looking and search for the new. In electrocardiography these are people like Adrian and the coauthors of this superb book. Thus, the general principle of advancement in scientific knowledge is telescopic learning and curiosity. Just imagine yourself within the history from 1901 (the string galvanometer of Einthoven) to the book that you have in your hands now in 2018. From the ones that recorded the first electrical signals of the heart (Muirhead, Waller, Einthoven) who hardly could understand them to the accumulated knowledge of nowadays, the history of electrocardiography is not only fascinating but a real adventure. Adrian contributes with this book another chapter in this adventure.
I congratulate Adrian and his coauthors for this book, which, without any doubt, is born as a milestone in the history of electrocardiography. Of obligatory reading for everybody involved in Medicine, whatever the area of interest.
Pedro Brugada
Lede
February 1, 2018
Preface
The Brugada phencopy (BrP) concept was born in Brazil and created by an astute electrocardiologist, Prof. Dr. Andrés Pérez-Riera, an Argentinean national who has spent most of his academic and professional career in Sao Paulo, Brazil.
Pérez-Riera noted that several publications referred to the existence of different clinical conditions present with an identical Brugada ECG pattern but in response to an underlying clinical condition. He thought that environmental
triggers were responsible to mimic a genetically predisposed condition. He coined the term BrP
and published a case of a patient receiving propofol who has developed, during the infusion, a Brugada ECG pattern. This was the beginning.
This was a captivating idea to me and wanted to explore this condition in detail. After several months of trying to find the needle in the haystack,
the first publication in the Annals of Noninvasive Electrocardiology brought several key
players in Brugada syndrome together to support the concept of BrP and the new definitions.
One of the decisions of the group had major implications in the definition of BrP: all cases of Brugada ECG pattern unmasked by sodium-channel blockers would not be considered as BrP, but rather as a possibly unmasked true genetically determined BrS. This led to the classification of BrP that had to be revised a year later with a publication in the American Journal of Cardiology. Since then, as more and more authors started to report their cases, the classification kept growing. In 2014, we decided to create a website, which contains an educational portal and more importantly, the international registry on BrP. The website was visited more than 6000 times (www.brugadaphenocopy.com) and created a permanent vehicle for investigators to interact with us, seeking for advice, reporting their cases, and exchanging ideas about how to diagnose and categorize the risk of each individual case. The very same year, a publication in the Canadian Journal of Cardiology, advanced a morphological classification, which helps researchers to categorize each case and unify terminology.
The ECG remains the cornerstone diagnostic method to suspect both Brugada syndrome and BrP. It is the clinical ability and the results of the sodium blocker challenge test, which helps discriminating one entity from another. The efforts of our team, in the first 5 years of life of BrP, were directed to help the physician in this regard. We still believe that educating the community in recognizing the Brugada ECG pattern is the foundation stone to assist patients and avoid misconceptions.
This book, Brugada Phenocopy: The Art of Recognizing the Brugada ECG Pattern, provides a straightforward and practical guide to analyze all aspects of this condition: including usual and unusual ECG presentations, sophisticated but easy ways to determine the presence of a Brugada ECG pattern and a systematic approach to differentiate true genetic Brugada syndrome from BrP.
I welcome all of you to read this book and discover the fascinating world of electrocardiology. The ECG remains alive as a productive, inexpensive, and everyday medical diagnostic tool.
Adrian Baranchuk
Kingston, ON,