ECG - Active Learning Conversation Around a 50M from Malaysia with a history of Sudden Cardiac Death in the family

[7/14, 7:19 PM] Professor 1: 50 year old Diabetic Male from Malaysia, with history of Sudden Cardiac Death in family, came for routine check..

[7/14, 7:21 PM] PG Student 1: Brugada syndrome
[7/14, 7:42 PM] Professor 1: 10 Steps of Decoding the ECG 👣

A. Heart Rate ⌚

B. Analyse and name the rhythm 🎶

C. Conduction normal or abnormal? 🚷

D. Axis of the QRS Complex ↘

E. Hypertrophy or enlargement of any chamber 💗

F. Ischemia or infarction  ♈

G. Clinical Context 🥵

H. Additional features ⛎

I. Final Interpretation 📝

J. Consult resources! 📲
[7/14, 7:42 PM] Professor 1: Maybe,.. may be not.. let's see tomorrow..🤓

Thanks for attempting..
[7/14, 8:35 PM] MBBS UG Student 1: I think it's Brugada Syndrome too.
[7/14, 8:38 PM] Professor 2: Please detail your inputs as per the ten steps mentioned above.
[7/14, 9:04 PM]  MBBS UG Student 1: -Diagnosis : Brugada Syndrome
-Normal standardisation
-Heart rate is around 100 bpm (Narrow QRS Complex Sinus Tachycardia) 
-Normal Rhythm 
-Normal Axis
-Normal P wave
-Normal PR interval 
-Coved ST segment elevation >2mm in leads V1-V3 followed by a negative T wave. (Brugada Sign) 
-Normal QT interval
-Family history of sudden cardiac death. 

-Treatment : ICD
[7/14, 9:38 PM] Professor 2: What could be the reason for that coved ST segment elevation in Brugada? 🤔
[7/14, 10:01 PM]  MBBS UG Student 1: "The presence of a deeply notched action potential in the RV epicardium, but not in
endocardium, would be expected to induce a transmural current that would contribute to
elevation of the ST-segment in the right precordial leads. The spike-and-dome configuration
may also prolong the epicardial action potential, thus contributing to a rapid reversal of the
transmural gradients and inscription of an inverted T-wave."


[7/14, 10:12 PM] Professor 2: 👍
[7/15, 8:58 PM] Professor 1: I congratulate and appreciate all those who attempted and shared their Valuable Knowledge..

👏🏽👏🏽


[7/15, 8:58 PM]Professor 1: Etiology of sudden cardiac arrest/sudden cardiac death..

🌴 90% are due to primary myocardial processes:

these include 

1) Acquired structural heart diseases like 

🌱coronary artery disease
🌱 Most cardiomyopathy

2) congenital heart diseases

3) inherited structural heart diseases like

🌱 Hypertrophic cardiomyopathy

🌱 Familial dilated cardiomyopathy

🌱 Arrhythmogenic right ventricular dysplasia.


🌴 the rest 10% cases of sudden cardiac death are due to primary electrical processes..

These include 

🌱Channelopathies..

🍒 Long or short QT syndrome.

🍒 Brugada syndrome

🍒 Catecholaminergic polymorphic VT

🌱 Acquired long QT syndrome: due to drugs, or electrolyte disorders..

🌱 Wpw syndrome

🌱Commodio cordis (VF triggered by blunt trauma to the chest wall)
[7/15, 9:00 PM] Professor 1: Excluded in this  classification are:

🥬 Massive pulmonary embolism

🥬 Aortic dissection

🥬 Master stroke..

All of these are causes of sudden death...

But the primary mechanism is outside the heart💞
[7/15, 9:01 PM] Professor 1: Let us study the ecg...
[7/15, 9:01 PM] Professor 1: Most of the points are covered here.. I will not repeat it..

If anyone find any discrepancy, please bring it to our notice.
[7/15, 9:02 PM] Professor 1: But I am a little old school..🤗 

I will try to approach It Like a student..🧐

[7/15, 9:04 PM] Professor 1: This is the pattern we were expecting..

Possibly thinking  of right bundle branch block..

And we may not be completely wrong... 

Let's see how much wrong or correct we are...😊
[7/15, 9:05 PM] Professor 1: The only issue We had is presence of St elevation like pattern in right side precordial leads...
[7/15, 9:08 PM] Professor 1: Focus on V1 V2 V3...

This is a pseudo rbbb pattern with St elevation...🧯

The J point is where QRS complex ends (meets the Isoelectric line)...

In this ECG, the J point is elevated more than two millimetre..🧐

Where is convexity aur school of the ST segment..

Descending terminal St elevation..

Negative T wave..

[7/15, 9:10 PM] Professor 1: This is an example of the most serious form of Brugada...

Aka type 1 Brugada...🧯

The characteristic findings as rightly pointed...

Are known as "brugada sign"
SHARK FIN APPEARANCE 
[7/15, 9:13 PM] Professor 1: What is type 2 brugada..?
[7/15, 9:15 PM] Professor 1: It is similar pseudo rbbb with St elevation .

The ST elevation, Rather J point elevation is more than or equal to 2 millimetre..

Saddleback ST-T segment.

Terminal St elevation greater than or equal to 1 millimetre..

Positive or sometimes biphasic T wave...

This is type 2 Brugada.

TYPE 3 BRUGADA

[7/15, 9:18 PM] Professor 1: J point elevation more than or equal to 2 mm..

Saddleback ST-T segment..

Terminal ST elevation lesser than 1 mm🧯

Positive T wave...

References :

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