A 39-year-old man with a Type 3 Brugada-type electrocardiogram (ECG) (Figure 1A), and no history of fainting, was admitted to the hospital for further evaluation. Although a slight ST-T change was observed during full-stomach test, Type 1 ECG pattern was not induced (Figure 1B). The next morning, the drug-induced test using a sodium channel blocker (pilsicainide 1 mg/kg; 10 mg bolus every 2 min over 10 min) was performed, however, the result was negative (Figure 1C). After the drug-induced test, he ate because he skipped his meal because of the procedure. Surprisingly, with the combination of the drug test and meal, a hidden Type 1 ECG pattern was revealed (Figure 1C).
Figure 1.
(A) Twelve-lead electrocardiogram on admission. (B) ST-T changes in lead V2 of 12-lead Holter electrocardiogram during meal and full-stomach test. Although a slight ST-T change was observed during full-stomach test, Type 1 Brugada electrocardiogram was not induced. ‘Max’ and ‘min’ indicate maximum and minimum ST deviation for 5 min, respectively. (C) ST-T changes in lead V2 of 12-lead Holter electrocardiogram during pilsicainide test and meal. Type 1 Brugada electrocardiogram was induced during meal 10 min after the end of pilsicainide test (white triangle indicates the beginning of the drug-induced test). ‘Max’ and ‘min’ indicate maximum and minimum ST deviation for 5 min, respectively.
In patients with suspected Brugada syndrome, a drug-induced test using a sodium channel blocker can be useful for diagnosis. A drug-induced test is often performed under fasting conditions to prevent complications when arrhythmia requiring cardioversion is induced. On the other hand, the Type 1 ECG pattern is also known to be induced by a full-stomach test in patients with Brugada syndrome. Although we cannot deny the possibility that Type 1 ECG changes could be the delayed response to pilsicainide, 10 min interval after the end of pilsicainide test suggests that the synergistic effects of pilsicainide and meal would be the likely mechanism.
Thus, we report here that caution must be needed about the condition of the drug testing and meals because a Type 1 ECG pattern may be induced even if the patient failed to show ECG changes through drug testing alone.
Consent: The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.