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Pauses on telemetry5/2/2023 ![]() Sinus node dysfunction (SND) in patients with Brugada has also been described and reported in the literature but remains clinically a less recognized and identified presentation. Supraventricular tachycardia and atrial fibrillation have been linked to BrS with an estimated incidence of 10-13%. The diagnosis of a syndrome is made based on the presence of the ECG pattern and the clinical presentation which may manifest as syncope or SCD classically attributed to ventricular arrhythmias and specifically polymorphic ventricular tachycardiac originating from the right ventricular outflow tract. It is characterized by a pseudo-right bundle branch block pattern on ECG with ST elevations in V1 and V2 that are either "coved" as in type 1 or "saddle back" as in type 2 (Figure 1). View Figure 4 Discussionīrugada syndrome (BrS) is a well-known arrhythmogenic entity associated with a risk of sudden cardiac death (SCD) due to ventricular fibrillation. He had a few more episodes of sinus pause documented and Mobitz 1 AV block on his event monitor which he reported were not associated with any syncopal events (Figure 4).įigure 4: Holter monitor strip demonstrates sinus pause. He was scheduled to follow up in clinic with recommendation to obtain an outpatient cardiac MRI to rule out infiltrative diseases. He deferred further procedures and elected to pursue outpatient cardiac event monitoring. Due to concerns of recurrent episodes, the patient was presented with different management options including the placement of a pacemaker or a dual chamber ICD and the future removal of the subcutaneous ICD. Multiple differential diagnoses were entertained including sinus node dysfunction in the setting of Brugada vs. Continuous telemetry monitoring revealed multiple episodes of sinus pauses of different durations at different times (Figure 3B). The patient received brief CPR before regaining consciousness. The episode was documented on the telemetry monitor and revealed a 12 second sinus arrest (Figure 3A). Unfortunately, after placement of his S-ICD, the patient had another syncopal episode associated with dizziness while he was in the hospital. After lengthy discussions with the patient about the different types of defibrillators, he elected to have a subcutaneous defibrillator (S-ICD) due to its cosmetic advantage, lack of vascular injury risk and low systemic infection risk (Figure 2). ![]() He was evaluated by general cardiology and electrophysiology and due to the concern for Brugada associated ventricular tachyarrhythmias as the culprit for his syncopal event, the placement of a defibrillator was recommended. His echocardiogram was unremarkable with normal chamber size, no hypertrophy or valvular disease and a left ventricular ejection fraction of 60%. His ECG showed sinus rhythm with coved ST segment elevation and T wave inversions in leads V1 and V2 consistent with type 1 Brugada pattern (Figure 1). ![]() His physical exam and laboratory workup were unremarkable. He does not take any medications and denied any family history of sudden cardiac death. He denied any pre or post syncopal symptoms of chest pain, palpitations, fevers, nausea, loss of bowel or bladder control or tongue biting. We review the relevant literature and discuss the management.Ī 31-year-old male with no significant past medical history presents after a witnessed syncopal episode. We present a case of a young patient who presented with syncope initially presumed to be secondary to a ventricular arrhythmia in the setting of newly diagnosed Brugada syndrome but was later found to have evidence of sinus node dysfunction. Sinus node dysfunction is a less recognized and acknowledged conduction abnormality associated with Brugada syndrome, but nevertheless an important potential manifestation that can alter management. Brugada Syndrome is a rare arrhythmogenic entity that poses a risk of sudden cardiac death due to ventricular arrhythmias. ![]()
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