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Acid Base, Electrolytes, Fluids

Brugada Pattern, Tall Peaked T Waves, Absence of P Waves, and Broad QRS Complexes

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JAMA Internal Medicine

Published Online: March 27, 2023

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Ziming Zhuang, MD¹;

Yangyi Lin, MD²

Author Affiliations

¹Department of Electrocardiology, Laizhou City Hospital of Traditional Chinese Medicine, Shandong Province, China
²Department of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

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A patient in their 70s presented to the emergency department with chest tightness and shortness of breath for 5 hours and loss of consciousness for 10 minutes. The patient’s medical history included metastatic rectal cancer and hypertension. On admission, the patient had a temperature of 36.0 °C, blood pressure of 52/26 mm Hg, pulse rate of 45 beats per minute, and respiratory rate of 6 breaths per minute. Examination revealed ecchymosis on the lower limbs, whereas cardiopulmonary examination was unremarkable. The N-terminal pro-brain natriuretic peptide level was 6770 ng/L (reference, 300-900 ng/L); however, the troponin I level was normal. A 12-lead electrocardiogram (ECG) obtained at admission is shown in Figure, A.

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Brugada phenocopy is a clinical entity in which patients present with an ECG pattern similar to that of true Brugada syndrome (BrS), yet it differs etiologically from true BrS. There have been reports of BrP for several clinical circumstances, such as hyperkalemia (as with the present patient), hypokalemia, coronary ischemia, mechanical compression (pectus excavatum, mediastinal tumors), acute pulmonary embolism, fever, and myocardial and pericardial disease (acute myocarditis and pericarditis).⁴ The most common cause of BrP described in the literature is hyperkalemia.⁵ Moreover, in patients with severe hyperkalemia, a BrP ECG is associated with a high prevalence of malignant arrhythmias (40%) and all-cause mortality (43%).⁶ The BrP ECG manifestations induced by hyperkalemia are attributed to depolarized resting membrane potential and a reduced inward sodium current.⁶

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Article Information

Corresponding Author: Yangyi Lin, MD, Department of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Beijing 100037, China (dr.linyangyi@outlook.com).

Published Online: March 27, 2023. doi:10.1001/jamainternmed.2022.7027

Conflict of Interest Disclosures: None reported.

References

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Rivera-Juárez A , Hernández-Romero I , Puertas C , et al. Clinical characteristics and electrophysiological mechanisms underlying Brugada ECG in patients with severe hyperkalemia. J Am Heart Assoc. 2019;8(3):e010115. doi:10.1161/JAHA.118.010115 PubMed Google Scholar Crossref

Littmann L , Gibbs MA . Electrocardiographic manifestations of severe hyperkalemia. J Electrocardiol. 2018;51(5):814-817. doi:10.1016/j.jelectrocard.2018.06.018 PubMed Google Scholar Crossref

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.