True Brugada pattern or only high V1-V2 electrode placement? Javier Garc´ıa-Niebla RN, Adri´an Baranchuck MD, FACC, FRCPC, Antonio Bay´es de Luna MD, PhD PII: DOI: Reference:
S0022-0736(14)00152-6 doi: 10.1016/j.jelectrocard.2014.04.020 YJELC 51866
To appear in:
Journal of Electrocardiology
Received date:
31 March 2014
Please cite this article as: Garc´ıa-Niebla Javier, Baranchuck Adri´ an, de Luna Antonio Bay´es, True Brugada pattern or only high V1-V2 electrode placement?, Journal of Electrocardiology (2014), doi: 10.1016/j.jelectrocard.2014.04.020
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT True Brugada pattern or only high V1-V2 electrode placement?
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Authors: Javier García-Niebla, RNa, Adrián Baranchuck, MD FACC, FRCPCb Antonio Bayés de Luna, MD, PhDc
PT
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Correspondence: Javier García-Niebla Valle del Golfo Health Center C/ Marcos Luis Barrera 1 38911 Frontera-El Hierro Islas Canarias-España Tel: +34 636 872 602 E-mail: [email protected]
MA NU
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Affiliations: a Servicios Sanitarios del Área de Salud de El Hierro. Valle del Golfo Health Center. Islas Canarias, España. b Division of Cardiology, Electrophysiology and Pacing, Queen’s University, Kingston General Hospital, Kingston, Ontario, Canada. c Institut Catala d’Ciencies Cardiovasculars. Hospital Santa Creu i Sant Pau. Barcelona, España.
CE
Dear Editor,
AC
We have read with interest the work by Chung et al (1) on the frequency of Brugada type patterns recorded by placing electrodes V1- V2 on the 2nd intercostal space. The study compared the ECGs of 491 pre-participation collegiate athletes with those of 181 non-athlete controls. Subjects underwent two ECGs at the time of their pre-participation physical examination: a baseline ECG with leads in the standard position, and a high precordial lead ECG with V1 and V2 moved up to the second intercostal space. Type 2 and 3 Brugada patterns were observed in both groups, but not type 1.
ACCEPTED MANUSCRIPT We would like to make few observations: - Echocardiography would have been helpful to rule out structural heart
RI P
T
disease.
- Before labeling these patterns as "Brugada patterns" the authors should
SC
have performed differential diagnosis with both normal and pathological
MA NU
conditions (2). When the V1- V2 electrodes are placed higher, it is common to register an rSr' pattern preceded by a negative P-wave similar to those shown in the article by Chung et al (Figure 1), especially in young men without heart disease and in the absence of pectus excavatum or
ED
straight back syndrome (2). This is because, at higher intercostal spaces
PT
(especially the 2nd), the head of the third vector of the ventricular
CE
depolarization directly faces lead V1- V2 electrodes and registers them as positive.The P-wave is negative due to the upward displacement, so the
AC
resulting atrial depolarization vector is further away from these electrodes and they therefore face the tail of the vector. In these cases the r' is usually narrow and must especially be distinguished from Brugada pattern type 2 (Figure 1C) (3). - New electrocardiographic criteria for the diagnosis of Brugada syndrome (4) can help distinguish between Brugada and non-Brugada ECG patterns. Chevalier et al (5) found greater alpha angles in patients with type 2 Brugada than in those with left bundle branch block (α > 50 °, sensitivity
ACCEPTED MANUSCRIPT 71%, specificity 79%) and greater beta angles (β > 58 °, sensitivity 79%, specificity 83%). Based on the work of Chevalier et al, we recently
T
described a new electrocardiographic criterion (6) which is easier to
RI P
measure and apply in daily practice. The length of the “base of the triangle”
SC
(≥ 160 ms or 4 mm) (Figure 2) formed by the ascending and descending branches of r' measured at 5 mm from the highest point allows one to
MA NU
distinguish between type 2 Brugada pattern and r' in elite athletes, with high sensitivity (85%) and specificity (95 %), On applying these ECG criteria to the figures shown by Chung et al in their article as examples
ED
quoted as possible Brugada patterns (Figure 3), we found that neither the
CE
ECG patterns.
PT
alpha/beta angles nor the base of the triangle are suggestive of Brugada
In conclusion, it appears that the pattern described by the authors is not in
AC
fact a Brugada pattern but rather a high placement of V1- V2 electrodes.
References 1. Chung EH, McNeely DE, Gehi AK, et al. Brugada type patterns are easily observed in high precordial lead ECGs in collegiate athletes. J Electrocardiol 2014; 47: 1. 2. Bayés de Luna A. Clinical Electrocardiography: A Textbook, 4th Ed. Wiley-Blackwell, Oxford, UK. 2012.
ACCEPTED MANUSCRIPT
3. García-Niebla J, Llontop-Garcia P, Valle-Racero J, et al. Technical
RI P
T
mistakes during the acquisition of the electrocardiogram. Ann Non inv Electrocardiol 2009; 14:389.
SC
4. Bayes de Luna A, Brugada J, Baranchuk A, et al. Current
MA NU
electrocardiographic criteria for diagnosis of Brugada pattern: a consensus report. J Electrocardiol. 2012; 45: 433.
5. Chevallier S, Forclaz A, Tenkorang J, et al. New electrocardiographic
ED
criteria for discriminating between Brugada types 2 and 3 patterns and
6. Serra
G,
PT
incomplete right bundle branch block. J Am Coll Cardiol 2011; 58: 2290. Baranchuk
A,
Bayes
de
Luna
A,
et
al.
New
CE
Electrocardiographic Criteria to Differentiate Type 2 Brugada pattern from
AC
ECG of Healthy Athletes with r'-wave in leads V1/V2. Europace 2014 (Epub ahead of print).
Figure legends Figure 1. ECG recording of a healthy 20 year-old male with V1-V2 electrodes placed correctly (A). On moving these electrodes to the 3rd intercostal space (B), the increased negative component of the P-wave in lead V1 and the appearance of negative P-wave in lead V2, together with
ACCEPTED MANUSCRIPT the rSr’ morphology, indicate high placement of these electrodes. On moving these electrodes to the 2nd intercostal space (C), the negative P-
T
wave together with the rSr’ morphology in leads V1 -V2 are indicative of
RI P
high electrode placement.
SC
Figure 2. Measuring the base of the triangle helps distinguish between a type 2 Brugada pattern and other patterns with r’ in leads V1 -V2. A base
MA NU
measuring ≥ 4 mm (160 ms) suggests a true Brugada pattern with high sensitivity (85 %) and specificity (95%).
ED
Figure 3. The alpha/beta angles and the length of the base of the triangle in
AC
CE
PT
the ECGs shown by Chung et al; do not suggest the Brugada pattern.
SC
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T
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ED
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Figure 1
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Figure 2
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ED
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PT
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Figure 3
S0022-0736(14)00152-6 doi: 10.1016/j.jelectrocard.2014.04.020 YJELC 51866
To appear in:
Journal of Electrocardiology
Received date:
31 March 2014
Please cite this article as: Garc´ıa-Niebla Javier, Baranchuck Adri´ an, de Luna Antonio Bay´es, True Brugada pattern or only high V1-V2 electrode placement?, Journal of Electrocardiology (2014), doi: 10.1016/j.jelectrocard.2014.04.020
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT True Brugada pattern or only high V1-V2 electrode placement?
RI P
T
Authors: Javier García-Niebla, RNa, Adrián Baranchuck, MD FACC, FRCPCb Antonio Bayés de Luna, MD, PhDc
PT
ED
Correspondence: Javier García-Niebla Valle del Golfo Health Center C/ Marcos Luis Barrera 1 38911 Frontera-El Hierro Islas Canarias-España Tel: +34 636 872 602 E-mail: [email protected]
MA NU
SC
Affiliations: a Servicios Sanitarios del Área de Salud de El Hierro. Valle del Golfo Health Center. Islas Canarias, España. b Division of Cardiology, Electrophysiology and Pacing, Queen’s University, Kingston General Hospital, Kingston, Ontario, Canada. c Institut Catala d’Ciencies Cardiovasculars. Hospital Santa Creu i Sant Pau. Barcelona, España.
CE
Dear Editor,
AC
We have read with interest the work by Chung et al (1) on the frequency of Brugada type patterns recorded by placing electrodes V1- V2 on the 2nd intercostal space. The study compared the ECGs of 491 pre-participation collegiate athletes with those of 181 non-athlete controls. Subjects underwent two ECGs at the time of their pre-participation physical examination: a baseline ECG with leads in the standard position, and a high precordial lead ECG with V1 and V2 moved up to the second intercostal space. Type 2 and 3 Brugada patterns were observed in both groups, but not type 1.
ACCEPTED MANUSCRIPT We would like to make few observations: - Echocardiography would have been helpful to rule out structural heart
RI P
T
disease.
- Before labeling these patterns as "Brugada patterns" the authors should
SC
have performed differential diagnosis with both normal and pathological
MA NU
conditions (2). When the V1- V2 electrodes are placed higher, it is common to register an rSr' pattern preceded by a negative P-wave similar to those shown in the article by Chung et al (Figure 1), especially in young men without heart disease and in the absence of pectus excavatum or
ED
straight back syndrome (2). This is because, at higher intercostal spaces
PT
(especially the 2nd), the head of the third vector of the ventricular
CE
depolarization directly faces lead V1- V2 electrodes and registers them as positive.The P-wave is negative due to the upward displacement, so the
AC
resulting atrial depolarization vector is further away from these electrodes and they therefore face the tail of the vector. In these cases the r' is usually narrow and must especially be distinguished from Brugada pattern type 2 (Figure 1C) (3). - New electrocardiographic criteria for the diagnosis of Brugada syndrome (4) can help distinguish between Brugada and non-Brugada ECG patterns. Chevalier et al (5) found greater alpha angles in patients with type 2 Brugada than in those with left bundle branch block (α > 50 °, sensitivity
ACCEPTED MANUSCRIPT 71%, specificity 79%) and greater beta angles (β > 58 °, sensitivity 79%, specificity 83%). Based on the work of Chevalier et al, we recently
T
described a new electrocardiographic criterion (6) which is easier to
RI P
measure and apply in daily practice. The length of the “base of the triangle”
SC
(≥ 160 ms or 4 mm) (Figure 2) formed by the ascending and descending branches of r' measured at 5 mm from the highest point allows one to
MA NU
distinguish between type 2 Brugada pattern and r' in elite athletes, with high sensitivity (85%) and specificity (95 %), On applying these ECG criteria to the figures shown by Chung et al in their article as examples
ED
quoted as possible Brugada patterns (Figure 3), we found that neither the
CE
ECG patterns.
PT
alpha/beta angles nor the base of the triangle are suggestive of Brugada
In conclusion, it appears that the pattern described by the authors is not in
AC
fact a Brugada pattern but rather a high placement of V1- V2 electrodes.
References 1. Chung EH, McNeely DE, Gehi AK, et al. Brugada type patterns are easily observed in high precordial lead ECGs in collegiate athletes. J Electrocardiol 2014; 47: 1. 2. Bayés de Luna A. Clinical Electrocardiography: A Textbook, 4th Ed. Wiley-Blackwell, Oxford, UK. 2012.
ACCEPTED MANUSCRIPT
3. García-Niebla J, Llontop-Garcia P, Valle-Racero J, et al. Technical
RI P
T
mistakes during the acquisition of the electrocardiogram. Ann Non inv Electrocardiol 2009; 14:389.
SC
4. Bayes de Luna A, Brugada J, Baranchuk A, et al. Current
MA NU
electrocardiographic criteria for diagnosis of Brugada pattern: a consensus report. J Electrocardiol. 2012; 45: 433.
5. Chevallier S, Forclaz A, Tenkorang J, et al. New electrocardiographic
ED
criteria for discriminating between Brugada types 2 and 3 patterns and
6. Serra
G,
PT
incomplete right bundle branch block. J Am Coll Cardiol 2011; 58: 2290. Baranchuk
A,
Bayes
de
Luna
A,
et
al.
New
CE
Electrocardiographic Criteria to Differentiate Type 2 Brugada pattern from
AC
ECG of Healthy Athletes with r'-wave in leads V1/V2. Europace 2014 (Epub ahead of print).
Figure legends Figure 1. ECG recording of a healthy 20 year-old male with V1-V2 electrodes placed correctly (A). On moving these electrodes to the 3rd intercostal space (B), the increased negative component of the P-wave in lead V1 and the appearance of negative P-wave in lead V2, together with
ACCEPTED MANUSCRIPT the rSr’ morphology, indicate high placement of these electrodes. On moving these electrodes to the 2nd intercostal space (C), the negative P-
T
wave together with the rSr’ morphology in leads V1 -V2 are indicative of
RI P
high electrode placement.
SC
Figure 2. Measuring the base of the triangle helps distinguish between a type 2 Brugada pattern and other patterns with r’ in leads V1 -V2. A base
MA NU
measuring ≥ 4 mm (160 ms) suggests a true Brugada pattern with high sensitivity (85 %) and specificity (95%).
ED
Figure 3. The alpha/beta angles and the length of the base of the triangle in
AC
CE
PT
the ECGs shown by Chung et al; do not suggest the Brugada pattern.
SC
RI P
T
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CE
PT
ED
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Figure 1
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Figure 2
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Figure 3
