Response to: Brugada Phenocopy: Morphological Classification and Importance of Provocative Testing

We thank Gottschalk et al. for their interest and comment on our case report of possible Brugada phenocopy in a patient with concomitant heroin and ethanol overdose.1

Heroin abuse and sudden death associated with heroin overdose has increased significantly during the past decade in the United States.2 In our case report, we observed electrocardiographic changes that were morphologically similar to Brugada syndrome in a man with concomitant heroin and ethanol overdose. The electrocardiographic (ECG) changes resolved during continuous infusion of naloxone. As explained in our report, the patient denied any prior palpitation, arrhythmia, chest pain, dizziness, syncope, or near‐syncope. Also, we mentioned in the report that provocative testing with a sodium channel blocker agent was not done, therefore, a true Brugada syndrome could not be absolutely excluded; however, a negative family history of syncope or sudden death makes the true Brugada syndrome less likely. We would also like to highlight the fact that the first and last electrocardiograms were recorded with same electrodes placement (i.e., electrodes remained in their position after first electrocardiogram until last electrocardiogram was done). Therefore, we think the significant electrocardiographic changes in leads V₁ and V₂ are unlikely due to displacement of electrodes.

In order to further investigate the case with provocative challenge test, we tried to contact the patient; however, due to circumstances beyond our control, our multiple attempts to find the patient were not successful. We agree with Gottschalk et al. that provocative challenge test plays a pivotal role in differentiating Brugada phenocopy from true Brugada syndrome. We too encourage the physicians who see cases of heroin overdose with ECG changes to further investigate the case with provocative challenge test. This phenomenon, if observed repeatedly, may shed more light on the increased cause of sudden death in patients with heroin overdose.