1. Induced Brugada Syndrome - what are the risks?
Susan P. Torrey, MD, FAAEM, FACEP
Associate Professor of Emergency Medicine
Tufts University School of Medicine
Baystate Medical Center, Springfield, MA

2. I have no financial disclosures,
but…
@STorreyMD

3. Brugada Syndrome Inherited Na+ channelopathy
Autosomal dom w/ incomplete penetrance
Sudden death (often during sleep)
Mean age 41 +/- 15 years
Men > woman (5.5 more common)
Prevalence (0.02% - 2%)
Asia > Europe > US

4. Sudden Unexpected Death in Sleep

5. Asian mythology Philippines – bangungut “to rise and moan”
Thailand – phi am “widow ghost”
Japan – pokkuri “pop-off”

6. Brugada syndrome, type I

7. Brugada syndrome

8. Brugada Syndrome Risk factors for suden death
Type I EKG
Hx V tach/V fib (arrhythmogenic syncope)
Family hx sudden death
Inducibility of VT/VF during EP study
ICD is the only effective preventive Rx
But it also has risk – 8.6%/year

9. Case presentation… 40 year old man – hx IVDA heroin
Arrives agitated and c/o back / chest pain
An EKG was obtained early --

10. Initial EKG

11. An old EKG was available

12. Case presentation… 40 year old man – hx IVDA heroin
Arrives agitated and c/o back / chest pain
An EKG was obtained early –
Interventional cardiology was alerted
Labs drawn on arrival return --

13. …never mind… K+ -- 7.8 mmol/L Cr -- 3.6 mg/dL (1.1 a month earlier)
CPK -- 28,960
Rhabdomyolysis with ATN
EKG – Induced Brugada 2° hyperkalemia
HyperK+ was aggressively Rx

14. Repeat EKG one hour later

15. Comparison of EKGs
Before Rx
After Rx

16. Induced Brugada syndrome
Loss of Na+ channel fx with increase temp
Reduced inward Na+ current
Na+ channel blockers
Cocaine, TCA, antihistamines
Increased outward K+ current
Hyperkalemia

17. Induced Brugada-type EKG, a sign for imminent malignant arrhythmias
Junttila M, et al. Circ 117: , 2008
47 pts with induced Brugada EKG
Occurred during acute medical care
69% male, mean age 48 years
Febrile episode – 16
Drug or medication – 26
Hyperkalemia – 5
24 (51%) developed sx; 18 (38%) with SCD

18. Induced Brugada-type EKG, a sign for imminent malignant arrhythmias
Junttila M, et al. Circ 117: , 2008
Drugs and medication
Propofol – 7
Flecainide – 5
Propafenone – 3
Atrial fib is prevalent in Brudaga, 11-14%

19. Middle-aged man with temp 102.9°

20. Fever-induced Brugada pattern: How common is it and what does it mean
Adler A, et al. Heart Rhythm 10: , 2013
Compared EKGs of patients +/- fever
402 pts with fever
909 pts without fever
Type I Brugada more common with fever
20X more common
2% vs 0.1%
Mean age 47 years / 87% male
Persistent Brugada EKG in only 1 patient

21. What is the risk? Monitoring and appropriate Rx No one really knows
Brudaga syndrome – low incidence
Induced Brugada - ?
But the reality exists that someone with induced Brugada will experience SCD
Not everyone with fever needs an EKG!
But, BrS EKG with known cause needs –
Monitoring and appropriate Rx