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

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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
1.
Pérez-Riera  AR , Barbosa-Barros  R , Daminello-Raimundo  R , de Abreu  LC , Baranchuk  A .  Unusual ST-segment elevation in the anterolateral precordial leads: ischemia, Brugada phenocopy, Brugada syndrome, all, or none?   Circulation. 2017;136(20):1976-1978. doi:10.1161/CIRCULATIONAHA.117.031632PubMedGoogle ScholarCrossref
2.
Hariman  RJ , Chen  CM .  Effects of hyperkalaemia on sinus nodal function in dogs: sino-ventricular conduction.   Cardiovasc Res. 1983;17(9):509-517. doi:10.1093/cvr/17.9.509PubMedGoogle ScholarCrossref
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Cairo  MS , Bishop  M .  Tumour lysis syndrome: new therapeutic strategies and classification.   Br J Haematol. 2004;127(1):3-11. doi:10.1111/j.1365-2141.2004.05094.xPubMedGoogle ScholarCrossref
4.
Baranchuk  A , Nguyen  T , Ryu  MH ,  et al.  Brugada phenocopy: new terminology and proposed classification.   Ann Noninvasive Electrocardiol. 2012;17(4):299-314. doi:10.1111/j.1542-474X.2012.00525.xPubMedGoogle ScholarCrossref
5.
Rajendran  G , Mahalingam  S , Ganessane  E .  Unusual presentation of a common diagnosis in a patient with chronic kidney disease.   JAMA Intern Med. 2022. doi:10.1001/jamainternmed.2022.4716PubMedGoogle ScholarCrossref
6.
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.118.010115PubMedGoogle ScholarCrossref
7.
Littmann  L , Gibbs  MA .  Electrocardiographic manifestations of severe hyperkalemia.   J Electrocardiol. 2018;51(5):814-817. doi:10.1016/j.jelectrocard.2018.06.018PubMedGoogle ScholarCrossref
8.
Baeksgaard  L , Sørensen  JB .  Acute tumor lysis syndrome in solid tumors–a case report and review of the literature.   Cancer Chemother Pharmacol. 2003;51(3):187-192. doi:10.1007/s00280-002-0556-xPubMedGoogle ScholarCrossref
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