Inherited and environmental
Brugada syndrome
Coved ST elevation with T inversion in V1–V2 — a sodium channelopathy that kills at night.
70 bpmSinus
What you see
- Type 1 (diagnostic): coved ST elevation ≥ 2 mm in V1–V2 descending into an inverted T wave.
- Type 2: saddleback ST elevation with an upright or biphasic T — suggestive, not diagnostic.
- A partial right bundle branch block appearance without the broad S wave in the lateral leads.
- The pattern comes and goes, and is unmasked by fever, alcohol or sodium channel blockers.
Why it looks like that
Loss-of-function mutations in the cardiac sodium channel gene SCN5A shorten the right ventricular epicardial action potential relative to the endocardium. That transmural voltage gradient produces the ST elevation and creates a substrate for phase 2 re-entry.
What to do
- Treat fever aggressively with antipyretics — fever unmasks the pattern and precipitates arrhythmia.
- Avoid the drugs listed on BrugadaDrugs.org: flecainide, propafenone, tricyclics, lithium, cocaine, and many others.
- ICD for survivors of cardiac arrest and for those with arrhythmic syncope; quinidine is an alternative in some.
- Family screening — inheritance is autosomal dominant with variable penetrance.
The trap
Type 2 and type 3 patterns are not diagnostic on their own and are common in healthy people; over-diagnosis leads to unnecessary devices. Conversely, an asymptomatic type 1 pattern found in a patient with a febrile illness deserves proper follow-up rather than dismissal.
SCN5Acoved STfeverICD