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Unusual ST-Segment Elevation in the Anterolateral Precordial Leads
2017; Lippincott Williams & Wilkins; Volume: 136; Issue: 20 Linguagem: Inglês
10.1161/circulationaha.117.031632
ISSN1524-4539
AutoresAndrés Ricardo Pérez‐Riera, Raimundo Barbosa‐Barros, Rodrigo Daminello Raimundo, Luíz Carlos de Abreu, Adrián Baranchuk,
Tópico(s)Phonocardiography and Auscultation Techniques
ResumoHomeCirculationVol. 136, No. 20Unusual ST-Segment Elevation in the Anterolateral Precordial Leads Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCase ReportPDF/EPUBUnusual ST-Segment Elevation in the Anterolateral Precordial LeadsIschemia, Brugada Phenocopy, Brugada Syndrome, All, or None? Andrés Ricardo Pérez-Riera, MD, PhD, Raimundo Barbosa-Barros, MD, Rodrigo Daminello-Raimundo, PhD, Luiz Carlos de Abreu, PhD and Adrian Baranchuk, MD Andrés Ricardo Pérez-RieraAndrés Ricardo Pérez-Riera Laboratório de Delineamento de Estudos e Escrita Científica da Faculdade de Medicina do André Bernardo Caetano (ABC), Santo André, São Paulo, Brazil (A.R.P.-R., R.D.R., L.C.d.A.). , Raimundo Barbosa-BarrosRaimundo Barbosa-Barros Centro Coronariano do Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil (R.B.-B.). , Rodrigo Daminello-RaimundoRodrigo Daminello-Raimundo Laboratório de Delineamento de Estudos e Escrita Científica da Faculdade de Medicina do André Bernardo Caetano (ABC), Santo André, São Paulo, Brazil (A.R.P.-R., R.D.R., L.C.d.A.). , Luiz Carlos de AbreuLuiz Carlos de Abreu Laboratório de Delineamento de Estudos e Escrita Científica da Faculdade de Medicina do André Bernardo Caetano (ABC), Santo André, São Paulo, Brazil (A.R.P.-R., R.D.R., L.C.d.A.). and Adrian BaranchukAdrian Baranchuk Division of Cardiology, Queen's University, Kingston, Canada (A.B.). Originally published14 Nov 2017https://doi.org/10.1161/CIRCULATIONAHA.117.031632Circulation. 2017;136:1976–1978ECG ChallengeThe patient is a 65-year-old white male with history of type 2 diabetes mellitus, hypertension, chronic smoking, and prior stroke with residual left hemiparesis and aphasia. His medication included losartan, furosemide, simvastatin, and metformin.He was admitted to the emergency room in cardiac arrest and was quickly resuscitated with cardiopulmonary resuscitation and external electric cardioversion maneuvers. Immediately after return of spontaneous circulation, a 12-lead ECG was performed (Figure 1).Download figureDownload PowerPointFigure 1. ECG performed immediately after cardiopulmonary arrest reversion.Based on the ECG, what is the most likely etiology of his cardiac arrest?Please turn the page to read the diagnosis.Response to ECG ChallengeThe firstECG shows accelerated junctional rhythm and a heart rate of 94 bpm, with J point and anterior ST elevation >2 mm. The correct diagnosis was acute ST elevation myocardial infarction. The patient underwent coronary angiography, which revealed proximal subocclusion of the left anterior descending coronary artery, with significant thrombus (Figure 2) successfully revascularized after placement of a drug-eluting stent. After the coronary intervention, we performed another ECG shown in Figure 3.Download figureDownload PowerPointFigure 2. Coronariography with and without obstruction. Left anterior oblique: left anterior descending coronary artery with 80% proximal obstruction with thrombus (A) and after drug-eluting stent placement (B).Download figureDownload PowerPointFigure 3. ECG performed after percutaneous coronary intervention. Absence of Q wave infarction initially, loss of ST elevation with QRS narrowing. These changes are likely representative of reperfusion T wave inversions afterward. The postischemic diffuse T wave inversion is observed in the anterolateral wall, coincident with left anterior descending (LAD) territory, including its first diagonal branch (proximal LAD territory obstruction).The initial ECG on presentation was compatible with ischemia-induced atypical Brugada phenocopy (BrP),1 confirmed later by negative provocative ajmaline test, indicating low probability of true Brugada syndrome (BrS).Brugada Phenocopy Emerging as a New ConceptBrP is a clinical entity in which patients present with an ECG pattern identical to either type 1 or 2 Brugada ECG patterns, yet it differs etiologically from true BrS. The defining feature of BrP is the absence of true congenital BrS. Therefore, a provocative testing with a sodium channel blocking agent such as ajmaline, flecainide, or procainamide will not reproduce the typical type 1 Brugada ECG pattern. The diagnostic criteria we have suggested for BrPs are the following (I–V are mandatory)1,2:Type 1 or 2 Brugada ECG patternUnderlying identifiable condition to explain the Brugada-like pattern on ECGThe ECG pattern immediately resolves on resolution of the underlying conditionLow clinical pretest probability of true BrS determined by a lack of symptoms and medical and family historyNegative provocative testing with ajmaline, flecainide, or procainamideProvocative testing is not mandatory if surgical right ventricular outflow tract manipulation has occurred within the last 96 hoursNegative genetic screening (mutations are identifiable in only 20% to 30% of cases affected by true BrS)Recently, Alper et al1 showed the first case of BrP with atypical type 1 Brugada ECG pattern located in inferior leads, emphasizing that Brugada-like syndromes have been reported to present as ST elevation in inferior leads.3The potential mechanisms and pathophysiology underlying BrP remain unclear. BrPs have been reported under a multitude of clinical circumstances in the following distinct etiologic categories1,2: metabolic conditions, endocrine disease (ie, hypopituitarism), electrolyte imbalances, mechanical compression (mediastinal tumors, pectus excavatum), ischemia-induced (the present case), myocardial and pericardial disease, acute pulmonary embolism, and others. For a detailed list of conditions, please refer to the Educational Portal and International Registry on Brugada Phenocopies (www.brugadaphenocopy.com).DisclosuresNone.FootnotesCirculation is available at http://circ.ahajournals.org.Correspondence to: Andrés Ricardo Pérez-Riera, MD, PhD, Rua Sebastião Afonso 885, 04417-100 Jd Miriam, São Paulo, Brazil. E-mail [email protected]References1. Alper AT, Tekkesin AI, Çinier G, Turkkan C, Baranchuk A. First description of a Brugada phenocopy in the inferior leads in the context of an acute inferior myocardial infarction.Europace. 2017; 19:1219. doi: 10.1093/europace/eux182.CrossrefMedlineGoogle Scholar2. Baranchuk A, Nguyen T, Ryu MH, Femenía F, Zareba W, Wilde AA, Shimizu W, Brugada P, Pérez-Riera AR. Brugada phenocopy: new terminology and proposed classification.Ann Noninvasive Electrocardiol. 2012; 17:299–314. doi: 10.1111/j.1542-474X.2012.00525.x.CrossrefMedlineGoogle Scholar3. Riera AR, Ferreira C, Schapachnik E, Sanches PC, Moffa PJ. Brugada syndrome with atypical ECG: downsloping ST-segment elevation in inferior leads.J Electrocardiol. 2004; 37:101–104.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Zhang L, Dong S, Zhao W, Li J, Cui L, Han Y and Chu Y (2021) Relationship Between an Ischaemic J Wave Pattern and Ventricular Fibrillation in ST-Elevation Myocardial Infarction Patients, International Journal of General Medicine, 10.2147/IJGM.S337638, Volume 14, (8725-8735) Li Y, Liu T, Tse G and Tao L (2020) Brugada phenocopy following coronary artery bypass graft surgery, Journal of Electrocardiology, 10.1016/j.jelectrocard.2020.02.006, 59, (134-139), Online publication date: 1-Mar-2020. Zakka P and Refaat M (2019) Brugada pattern, Brugada phenocopy, or Brugada syndrome: That is the question, Pacing and Clinical Electrophysiology, 10.1111/pace.13676, 42:7, (777-778), Online publication date: 1-Jul-2019. de Oliveira Neto N, de Oliveira W, Mastrocola F and Sacilotto L (2019) Brugada phenocopy: Mechanisms, diagnosis, and implications, Journal of Electrocardiology, 10.1016/j.jelectrocard.2019.04.017, 55, (45-50), Online publication date: 1-Jul-2019. Xu G, Gottschalk B, Pérez‐Riera A, Barbosa‐Barros R, Dendramis G, Carrizo A, Agrawal S, Bayés de Luna A, Jastrzębski M, Tomcsányi J and Baranchuk A (2019) Link between Brugada phenocopy and myocardial ischemia: Results from the International Registry on Brugada Phenocopy, Pacing and Clinical Electrophysiology, 10.1111/pace.13678, 42:6, (658-662), Online publication date: 1-Jun-2019. Borgaonkar S and Birnbaum Y (2019) ST-Segment Elevation Soon after Coronary Artery Bypass Grafting, Texas Heart Institute Journal, 10.14503/THIJ-18-6783, 46:2, (155-156), Online publication date: 1-Apr-2019. Gul E, Haseeb S, Al Amoudi O and Baranchuk A (2018) Brugada phenocopy associated with left ventricular aneurysm, Journal of Electrocardiology, 10.1016/j.jelectrocard.2018.08.032, 51:6, (963-965), Online publication date: 1-Nov-2018. Gottschalk B, Garcia-Niebla J and Baranchuk A (2018) Letter by Gottschalk et al Regarding Article, "Cardiac Arrest With ST-Segment–Elevation in V1 and V2: Differential Diagnosis", Circulation, 138:18, (2067-2068), Online publication date: 30-Oct-2018. García-Niebla J, Bayés de Luna A and Baranchuk A (2018) Multifactorial Brugada Phenocopy, JAMA Internal Medicine, 10.1001/jamainternmed.2018.2012, 178:6, (872), Online publication date: 1-Jun-2018. November 14, 2017Vol 136, Issue 20 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.031632PMID: 29133531 Originally publishedNovember 14, 2017 PDF download Advertisement
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