The patients suffering from Brugada syndrome may present to a doctor with various complaints, however, most frequently, these complaints are related to cardiovascular system and/or alterations in electrocardiographic (ECG) patterns.

Syncope is one of the most common manifestations of Brugada syndrome.

Cardiac arrest is another common presentation in these patients.
The patients of Brugada syndrome sometimes complain of nightmares.

Atrial fibrillation is the presentation in about 20% of the cases of Brugada syndrome [7].

Sometimes fever is reported and it also triggers the cardiac events in patients of Brugada syndrome.

Heart murmurs are also present in Brugada syndrome.

• Family History of Epilepsy

  history of SCD Dizziness palpitations, syncope 52 10 3 pre-syncopes with sinus bradycardia, 1 syncope without ILR triggering None Misdetection of QRS complexes, artefacts Patient no. 4: ECG Type 2 family history of epilepsy Dizziness, palpitations, pre-syncope [doi.org]

• Hypercapnic Respiratory Failure

  On further evaluation, she was found to have hypoxic and hypercapnic respiratory failure and was placed on bilevel positive airway pressure ventilation. [ncbi.nlm.nih.gov]

• Tachycardia

  This report documents a case of Brugada syndrome and polymorphic ventricular tachycardia-ventricular fibrillation not initially recognized in a patient taking nortriptyline and experiencing syncope. [ncbi.nlm.nih.gov]

  Adenosine-induced, sudden bradycardia and subsequent tachycardia have also been investigated to identify QT changes of diagnostic value in patients with LQTS. [doi.org]

• Heart Disease

  Brugada syndrome (BrS) is a cardiac ion channel disease that is caused by an autosomal dominant genetic abnormality. A ventricular septal defect is a common congenital heart disease, in which genetic defects play a significant role. [ncbi.nlm.nih.gov]

  EKG Right bundle branch block; persistent ST-segment elevation in V1 to V3, unexplained by electrolyte disturbances; ischaemia; structural heart disease. Management Implantable defibrillator. [medical-dictionary.thefreedictionary.com]

• Pericardial Friction Rub

  Acute pericarditis may appears with chest pain, fever, pericardial friction rub, and cardiac tamponade. Moreover, widespread ST segment changes occur due to involvement of the underlying epicardium. [ncbi.nlm.nih.gov]

• Long Arm

  arm of chromosome 14, Genomics, 1996, vol. 31 (pg. 193 - 200 ) [17] ARVD4, a new locus for arrhythmogenic right ventricular cardiomyopathy, maps to chromosome 2 long arm, Genomics, 1997, vol. 15 (pg. 259 - 263 ) [18] Gene for arrhythmogenic right ventricular [doi.org]

Brugada syndrome requires complete work-up and laboratory investigations for proper diagnosis. The investigations relevant to Brugada syndrome are listed below:

• Genetic testing has an important role in the diagnosis of the patients of Brugada syndrome. In addition to the diagnosis, genetic testing can help in identifying the relatives who are at risk for developing Brugada syndrome. [8]

• Electrocardiography (ECG) is the key investigation for the patients of Brugada syndrome. This is because some patients of Brugada syndrome may apparently be asymptomatic but still have the underlying electrocardiographic changes of this disease. For diagnostic purposes, these changes can also be induced by administration of some anti-arrhythmic drugs. Brugada syndrome has three different electrocardiographic patterns: ST-elevation (type 1), Saddleback pattern (type 2), A combination of type 1 or type 2.

• Brugada syndrome can be investigated by inducing arrhythmias with the use of electro-physiologic studies (EPS).

• Serum calcium and potassium levels should be evaluated because variations in their levels can produce the same electrocardiographic patterns as commonly seen in Brugada syndrome.

• Creatine kinase MB (CK-MB) and troponin levels should be evaluated to rule out any underlying heart condition e.g. acute coronary syndrome (ACS).

• Echocardiography and Magnetic resonance imaging (MRI) are used to rule out any arrhythmogenic condition that mimics Brugada syndrome.

• Bicytopenia

  Laboratory work up revealed bicytopenia (white cell count 1.37×10(9)/L, platelets 60×10(9)/L) and an increase in C reactive protein (9 mg/dL). The ECG showed ST segment elevation in V1, V2 and V3 leads. [ncbi.nlm.nih.gov]

• Hypertriglyceridemia

  The patient was admitted and investigation was initiated revealing prolonged fever (>7 days), pancytopenia, hepatosplenomegaly, hyperferritinemia, hypertriglyceridemia, hypofibrinogenemia, elevated soluble CD25 and hemophagocytosis in bone marrow. [ncbi.nlm.nih.gov]

• Right Bundle Branch Block

  KEYWORDS: Brugada syndrome; ajmaline challenge; arrhythmia; depolarization; electrocardiography; endocardium; epicardium; repolarization; right bundle branch block; right ventricular outflow tract; sudden death [ncbi.nlm.nih.gov]

  1998, vol. 97 (pg. 457 - 460 ) [35] Familial cardiomyopathy underlies syndrome of right bundle branch block, ST segment elevation and sudden death, J Am Coll Cardiol, 1996, vol. 27 (pg. 443 - 448 ) [36] Pathologic substrates of right bundle branch block [doi.org]

  EKG Right bundle branch block; persistent ST-segment elevation in V1 to V3, unexplained by electrolyte disturbances; ischaemia; structural heart disease. Management Implantable defibrillator. [medical-dictionary.thefreedictionary.com]

  A right bundle branch block can mimic BS, but differs in that the ST-segment is not elevated in leads V1-V2 and the QRS is wider than in BS. [acc.org]

• Prominent U Wave

  QT measurement during adrenaline infusion can be challenging to interpret in the context of dynamic T-wave morphology changes, particularly when prominent U waves are present, the T wave is flattened or when notching of the T wave occurs. [doi.org]

The best option for the treatment of syncope and cardiac arrest in the patients of Brugada syndrome is the placement of an automatic implantable cardiac defibrillator (ICD). As mentioned earlier, the patients suffering from Brugada syndrome usually die of ventricular fibrillation. If a defibrillating device is in place, episodes of ventricular fibrillation will be promptly reversed and the patient’s life will be saved.

Recent studies have shown that quinidine decreases the episodes of ventricular defibrillation [9]. It may also be used for the treatment of Brugada syndrome in selected cases.

Regular exercise should be stopped as it increases the vagal tone, thereby increasing the risk of ventricular fibrillation.
Long term follow up is necessary for all the patients suffering from Brugada syndrome.

Prognosis depends largely upon the long term proper follow-up. Prognosis is good with proper treatment and management.

Without treatment, sudden cardiac death occurs in men under 40 years of age. With proper placement of implanted cardiac defibrillator, life expectancy and quality of life are improved.

The mean age of sudden death in patients suffering from Brugada syndrome is 41+/- 15 years [10].

Brugada syndrome is primarily caused by mutations in SCN5A gene, although mutations in other genes are also seen in some cases [5]. Variants of Brugada syndrome can be caused by the mutations in the genes that code subunits of the L-type calcium channel (CACNA1C and CACNB2).

Some cases of Brugada syndrome also carry mutations in GPD1-L and SCN1B genes. Besides, some conditions and diseases can exaggerate or unmask electrocardiographic changes of Brugada syndrome. Some of them are listed below.

• Fever can cause variations in electrocardiographic (ECG) pattern in patients of Brugada syndrome [6].
• Potassium level homeostasis is of prime important in cases of Brugada syndrome. This is because both hypokalemia and hyperkalemia can cause exaggeration of Brugada syndrome.
• As with potassium, monitoring of the calcium level is also important in cases of Brugada syndrome because fluctuations of calcium level can exacerbate the condition.
• Alcohol or cocaine abuse also causes exacerbation of the condition.
• Medications like sodium channel blockers, vagotonic agents, alpha adrenergic agonists, beta adrenergic blockers, heterocyclic antidepressants, and a combination of glucose and insulin cause worsening of Brugada syndrome and associated electrocardiographic changes.

Brugada syndrome is predominantly a disease of Asian people. It is much less common in the Western world. It is also much more prevalent in men as compared to women [4].

Several different mutations can result in Brugada syndrome. The underlying pathophysiology therefore varies with different genes. The voltage gated sodium channels of the heart are encoded by the SCN5A gene. Therefore, when the mutation is in the SCN5A gene - the most common mutation in Brugada syndrome - the cardiac voltage gated sodium channels do not function normally.

Abnormal voltage-gated sodium channels directly affect the cardiac action potential by reducing the sodium current available during the phases 0 (upstroke) and 1 (early repolarization). This reduction in sodium current then affects the endocardium of the right ventricle and leads to the clinical manifestations as well as the electrocardiographic variations that characterize Brugada syndrome.

The T wave remains upright and causes a saddleback electrocardiographic pattern when the usual time duration of repolarization is not changed.

Mutations in Glycerol-3-phosphate dehydrogenase 1-like (GPD1L) gene are also seen in some patients of Brugada syndrome. This gene acts as ion channel modulator in the heart muscle.

There are no guidelines for prevention of Brugada syndrome.

Brugada syndrome is a clinic-pathological entity that is characterized by an increased risk of sudden cardiac death as well as certain electrocardiographic (ECG) changes in the heart; most commonly the elevation of the ST segment in the precordial leads.

Brugada syndrome is a genetically pre-determined condition. The pattern of inheritance is autosomal dominant in as many as 50% of the familial cases. Brugada syndrome is the major cause of sudden unexplained death syndrome (SUDS) [1].

It is known to be one of the major causes of sudden death in young men without any previously diagnosed cardiac disorders [2].

Sudden death in Brugada syndrome results from ventricular fibrillation and arrhythmias. Electrocardiographic changes are observed in the patients who survive cardiac arrest [3].

Brugada syndrome is a genetic disease that affects the heart at a cellular level. In some patients, it produces no symptoms and remains undetected. In others, it causes symptoms related to the heart.

The patients who receive proper treatment and follow-up have a good prognosis. If untreated, it can cause sudden death in young patients (below 40 years of age) even in the absence of other heart diseases.

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