JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Quinidine, a Class Ia antiarrhythmic drug with Ito and IKr blocker effects, has been shown to prevent induction of VF and suppress spontaneous ventricular arrhythmias in a clinical setting. Quinidine is currently being used in patients with ICD and multiple shocks; cases in which ICD implantation is contraindicated; or for the treatment of supraventricular arrhythmias. 17 It has been suggested that quinidine could also be useful in children with Brugada syndrome, as a bridge to ICD or as an alternative to it. 17 Randomized studies on the use of quinidine, however, have not been performed. Radiofrequency Ablation (RFA) of ventricular ectopy has been postulated as a therapeutic approach in Brugada syndrome patients. A recent study by Josep Brugada et al. showed prevention and treatment of Brugada syndrome by RFA. This study had pathophysiologic and therapeutic implications. Substrate epicardial mapping and ablation guided by provocative testing was considered a reproducible, safe and effective strategy to definitively treat patients with type 1 Brugada syndrome EKG pattern and risk of sudden death. 19
pathophysiological mechanism. Cirulation 1999;78:581. 6. Arnon Adler, et al. Fever-induced Brugada pattern: How common is it and what does it mean? Heart Rhythm. 2013;10(9):2-5. 7. Benito B, Brugada J, Brugada R, Brugada P. Brugada syndrome. Rev Esp Cardiol. 2009;62:1297–1315. 8. Dumaine R, Towbin JA, Brugada P, Vatta M, Nesterenko DV, Nesterenko VV, Brugada J, Brugada R, Antzelevitch C. Ionic mechanisms responsible for the electrocardiographic phenotype of the Brugada syndrome are temperature dependent. Circ Res. 1999;85:803–809. 9. Deschênes I, Laurita KR. How can a single mutation cause such arrhythmic havoc? Heart Rhythm. 2007;4:198–199. 10. Vohra Jitendra, et. al. Update on the Diagnosis and Management of Brugada Syndrome. Heart, Lung and Circulation. 2015;24:1141–1148. 11. Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, Gussak I, LeMarec H, Nademanee K, Perez Riera AR, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation. 2005;111:659–670. 12. Nguyen T, Smythe J, Baranchuk A. Rhabdomyoma of the interventricular septum presenting as a Brugada phenocopy. Cardiol Young. 2011;21:591– 594. 13. Probst V, Veltmann C, Eckardt L, et al. Long-term prognosis of patients diagnosed with Brugada syndrome. Results from the FINGER Brugada Syndrome Registry. Circulation 2010;121(5):635-43. 14. Brugada J, Brugada R, Antzelevitch C, et al. Long-term follow-up of individuals with the electrocardiographic pattern of right bundle-branch block and STsegment elevation in precordial leads V1 to V3. Circulation 2002;105(1):73-8. 15. Brugada J, Brugada R, Brugada P. Determinants of sudden cardiac death in individuals with the electrocardiographic pattern of Brugada syndrome and no previous cardiac arrest. Circulation 2003;108(25):3092-6. 16. Priori SG, Gasparini M, Napolitano C, et al. Risk stratification in Brugada syndrome: results of the PRELUDE (PRogrammed ELectrical stimUlation preDictive valuE) registry. J Am Coll Cardiol 2012;59(1):37-45. 17. Mizusawa Y, Wilde AA. Brugada syndrome. Circ Arrhythm Electrophysiol. 2012;5:606–616. 18. Priori Silvia G., et.al. HRS/EHRA/APHRS Expert Consensus Statement on the Diagnosis and Management of Patients with Inherited Primary Arrhythmia Syndromes. Heart Rhythm 2013;10(12): 1937-1940. 19. Brugada Josep, et.al. Brugada Syndrome Phenotype Elimination by Epicardial Substrate Ablation. Circulation 2015;8(6):1373-1381.
CONCLUSION
The Brugada pattern includes a pattern resembling RBBB with elevation of the ST segment in the precordial leads (V1- V2). Physicians should be aware of other causes inducing ST segment elevation. A good clinical history and a low clinical suspicion for ischemia may avoid the inappropriate utilization of emergency catheterization and of hospital resources. Fever has been described to induce a Brugada-type EKG pattern in asymptomatic patients with a negative family history. 12 The expert consensus statement from the HRS/EHRA/APHRS gives a class I indication to provide immediate treatment of fever with antipyretic drugs. 3 Furthermore, avoidance of excessive alcohol intake and drugs that may induce or aggravate ST-segment elevation in right precordial leads are class I indications. Risk stratification of asymptomatic patients with a Brugada-type EKG induced by fever and a negative family history remains a matter of debate. According to current guidelines, careful follow-up would be an appropriate option. 11 The diagnostic value of a drug challenge test as well as electrophysiological studies in this population is uncertain. Our patient was asymptomatic with a negative family history and given close follow up. REFERENCES 1. Bayés de Luna A, Brugada J, Baranchuk A, et al. Current electrocardiographic criteria for diagnosis of Brugada pattern: a consensus report. J Electrocardio l. 2012;45:433-442. 2. Probst V, Wilde AA, Barc J, et al. SCN5A mutations and the role of genetic background in the pathophysiology of Brugada syndrome. Circ Cardiovasc Genet. 2009;2:552-557. 3. S.G. Priori, A.A. Wilde, M. Horie, Y. Cho, E.R. Behr, C. Berul, et al. HRS/EHRA/ APHRS Expert Consensus Statement on the Diagnosis and Management of Patients with Inherited Primary Arrhythmia Syndromes: Document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013 Heart Rhythm, 10 (2013), pp. 1932–1963. 4. Behr ER, Dalageorgou C, Christiansen M, Syrris P, Hughes S, Tome, Esteban MT, Rowland E, Jeffery S, McKennaWJ. Sudden arrhythmic death syndrome: familial evaluation identifies inheritable heart disease in the majority of families. Eur Heart J. 2008;29:1670–1680. 5. Alings M. Wilder A. “Brugada” Syndrome: clinical data and suggested
Dr. Tadin is a cardiology fellow at LSUHSC-New Orleans; Dr. Quintal is a retired chief of cardiology at LSU and at Touro Infirmary, both in New Orleans .
14 J La State Med Soc VOL 169 JANUARY/FEBRUARY 2017
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