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Bifid T waves induced by isoprenaline in a patient with Brugada syndrome
  1. Department of Internal Medicine,
  2. Carolinas Medical Center,
  3. Charlotte, NC 28232–2861, USA

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Sir,—Washizuka et aldescribe a patient with syncope, believed to have Brugada syndrome, who developed bifid T waves when given isoprenaline.1 The three ECGs reproduced in their figs 1 and 3, however, fail to show either incomplete or complete right bundle branch block, a hallmark and sine qua non characteristic of the Brugada syndrome. In addition, there is no significant ST segment elevation in lead V1, and the ST segment elevation in V2 is not at all coved-type. The characteristics of Brugada syndrome—right bundle branch block, ST segment elevation, and sudden cardiac death—are all missing.2 I am afraid that by injudiciously extending the scope of the Brugada syndrome to include a variety of non-specific electrocardiographic findings in patients who present with syncope, we will see this fascinating entity itself succumb to sudden death.


This letter was shown to the authors, who reply as follows:

The ECG of Brugada syndrome characterised by right bundle branch block and persistent ST elevation is known to show day to day variation. The ECG of our patient recorded on another day showed prominent coved-type ST elevation. Class IA drugs accentuated the magnitude of ST elevation, the patient had a history of unexplained syncope, and ventricular fibrillation was induced during electrophysiological study.

As pointed out by Littmann it is difficult to diagnose Brugada syndrome from ECG recordings; however, ECG pattern changes from time to time and the administration of intravenous class IA drugs may unmask the ECG pattern1-1 as in our case. In addition, it was suggested that a prominent J wave was part of the ECG abnormality.1-2 1-3 So a clear diagnosis may be difficult from single ECG recording and we should be careful of diagnosis of Brugada syndrome.


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