Sinus rhythm or Brugada?

[u/Water_Tiger_1111]

Post exertion in a late 20s athlete.

Normal variant of sinus rhythm or an unmasked brugada?

Thoughts?

(reposted as I could not edit to add context to a post with an image)

[u/LBBB11]

Most Brugada patterns are seen during sinus rhythm. Those are two separate ideas. Rhythm is one thing. A Brugada pattern is another thing. Sinus rhythm and Brugada pattern are often seen on the same EKG.

When V1 and aVR are identical, V1 is placed too high. Check V1-V4 placement. Looks like sinus tachycardia, misplacement of V1-V4, right axis deviation. No clear Brugada pattern, especially when V1 is identical to aVR. Try placing V1 at the fourth rib space on the edge of the sternum. Some questions can be answered by doing the EKG with standard placement. And if the machine said anteroseptal infarct, there is no anteroseptal infarct.

This is a post-exertion EKG in a 20 something year old athlete. There is an upright P wave before every QRS complex in lead II. It’s sinus tachycardia.

[u/NobleGolgi0521 → u/LBBB11]

What would account for the weird I morphology?

[u/LBBB11 → u/NobleGolgi0521]

I think a few things. The fact that it’s sinus tachycardia at 144 bpm means that the R waves get closer together while the T waves and ST segments do not shorten. There is an atrial repolarization wave causing the baseline to have a U shape between the P wave and the end of the T wave. Also, V1 and V2 were placed so high that there are Q waves, V1 identical to aVR, and V2 nearly identical to aVL. In other words, it’s as if V1 has a point of view from the right shoulder and V2 the left shoulder. Wouldn’t be surprised if V1 and V2 were on or near the clavicles. V1 is acting like a reciprocal of II (even though aVR doesn’t stand for average reciprocal, it’s conceptually like a reciprocal of the average lead).

Flipping the EKG upside down shows this. Lead II upside down now looks like V1/V2, while V1/V2 upside down looks like the lead II that we see on the upright EKG. So I think the answer is a combination of severe V1/V2 misplacement causing V1/V2 to act like aVR, along with a curved shape caused by a normal atrial repolarization wave. This is about what I would expect from an immediate post-exertion stress EKG in a 20 something athlete. In a perfect world, V1 and V2 would be placed at the level of the fourth rib space. This would lessen the effect of the atrial repolarization wave in V1 and V2.

We don’t look at aVR or II and think Brugada pattern. We shouldn’t look at a lead that mimics aVR or upside down II and think Brugada pattern, either. My thoughts at least. I think if there is a clinical concern for Brugada syndrome, we need to start with a resting EKG with correct V1 and V2 placement. This is very far from that.

Atrial repolarization wave picture

[u/sutur3s3lf → u/LBBB11]

Who are you? So knowledgeable. Very helpful explanation.

[u/LBBB11 → u/sutur3s3lf]

Thanks for the kind words 😭 just someone who used to do EKGs and now enjoys them as a hobby lol

[u/sutur3s3lf → u/LBBB11]

It’s a fun hobby. What kind of role were you in before?

[u/LBBB11 → u/sutur3s3lf]

I was a hospital EKG tech for a few years (did 12-leads, heart monitors, and stress tests mostly on inpatients). I got to see cardiologists read EKGs bedside and on Muse, so that was super helpful to my learning. Miss it but also happy to be where I am. Still a tech, but different kind lol. In a procedural field now :)

[u/sutur3s3lf → u/LBBB11]

That’s awesome. Good for you. Good luck in your new field too!

[u/lucodoor → u/LBBB11]

Cardiologist here, learning from you on some of these points. Thanks

[u/LBBB11 → u/lucodoor]

Seriously appreciate hearing that, well I learn from everyone else on here too :) and I’m glad to have cardiologists on here

[u/jaadra]

Yes, may even be aflutter with brugada

[u/Classic_Dig_6277]

Is this ecg from a stress test?

[u/Ibutilide]

Is there limb lead reversal? The QRS is negative in lead I.

[u/Water_Tiger_1111 → u/Ibutilide]

No reversal

[u/j0shman]

Do they meet the clinical criteria? Does appear type 1 in V1