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Gepubliceerd in: Netherlands Heart Journal 12/2015

Open Access 08-10-2015 | Rhythm Puzzle Answer

An unexpected ECG finding

Auteurs: Mathijs Kuiper, Albert Willems, Arthur A.M. Wilde

Gepubliceerd in: Netherlands Heart Journal | Uitgave 12/2015

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Answer

The ECG in Fig. 1 shows a sinus rhythm of 90 bpm with an intermediate axis, PQ delay of 202 ms and a narrow QRS complex. Convex ST elevation is seen in the right precordial leads. The ECG could be considered suspicious for acute septal myocardial infarction. However, reciprocal ST-segment changes are lacking and the QRS complex does not show any suspect abnormalities either. The ECG also has aspects of hyperkalaemia; in particular the sharp high voltage T waves point in that direction. The ECG in Fig. 1 is also compatible with a type 1 Brugada pattern. The patient has never had any cardiac symptoms, nor a family history of acute cardiac death.
The patient was admitted to the intensive care unit for rhythm monitoring. Hyperkalaemia was based on the use of high-dose spironolactone, in combination with dehydration and accordingly matched the patient’s comorbidity. Figure 2 shows the ECG taken after correction of the hyperkalaemia (5.2 mmol/l). This ECG returned to normal in a period of 4 h, without ST elevation and no signs of Brugada. Considering this short period of time to normalisation, there is a strong possibility that high potassium levels are provoking this Brugada pattern, as has been described before [1, 2]. Subsequently, Brugada syndrome was confirmed by positive ajmaline provocation testing. Shortly after administration of ajmaline the exact same type of Brugada was reproduced (with alternative placement of leads V3 and V5 to the intercostal space above V1 and V2, respectively; Fig. 3). This drug-induced Brugada syndrome is considered to be a type with a low risk of acute cardiac death [3]. However, in general it is recommended to prevent fever and if fever occurs to perform an ECG for potential rhythm monitoring, and to avoid certain drugs with the potential to prolong the QT interval.

Conclusion

Hyperkalaemia-induced Brugada syndrome.
Conflict of interest
None of the authors have any conflict of interest related to this report.
Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.
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Netherlands Heart Journal

Het Netherlands Heart Journal wordt uitgegeven in samenwerking met de Nederlandse Vereniging voor Cardiologie en de Nederlandse Hartstichting. Het tijdschrift is Engelstalig en wordt gratis beschikbaa ...

Literatuur
1.
go back to reference Littmann L, Monroe MH, Taylor L 3rd, Brearley WD Jr. The hyperkalaemic Brugada sign. J Electrocardiol. 2007;40:53–9.CrossRefPubMed Littmann L, Monroe MH, Taylor L 3rd, Brearley WD Jr. The hyperkalaemic Brugada sign. J Electrocardiol. 2007;40:53–9.CrossRefPubMed
2.
go back to reference Postema PG, Vlaar AP, DeVries JH, Tan HL. Familial Brugada syndrome uncovered by hyperkalaemic diabetic ketoacidosis. Europace. 2011;13:1509–10.CrossRefPubMed Postema PG, Vlaar AP, DeVries JH, Tan HL. Familial Brugada syndrome uncovered by hyperkalaemic diabetic ketoacidosis. Europace. 2011;13:1509–10.CrossRefPubMed
3.
go back to reference Mizusawa Y, Wilde AAM. Arrhythmogenic disorders of genetic origin: brugada Syndrome. Circ Arrhythm Electrophysiol. 2012;5:606–16.CrossRefPubMed Mizusawa Y, Wilde AAM. Arrhythmogenic disorders of genetic origin: brugada Syndrome. Circ Arrhythm Electrophysiol. 2012;5:606–16.CrossRefPubMed
Metagegevens
Titel
An unexpected ECG finding
Auteurs
Mathijs Kuiper
Albert Willems
Arthur A.M. Wilde
Publicatiedatum
08-10-2015
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 12/2015
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-015-0758-6

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Rhythm Puzzle Question

An unexpected ECG finding