Diagnostic Considerations

The differential diagnosis of cardiac arrest in an otherwise presumably healthy subject is varied, but it includes such entities as acute cardiac ischemia due to atherosclerosis or coronary anomaly, hypertrophic cardiomyopathy, catecholaminergic polymorphic ventricular tachycardia, long QT syndrome, and arrhythmogenic right ventricular cardiomyopathy (ARVC). Many of these entities can be differentiated on the basis of history and physical examination. Occasionally, however, there is overlap that requires special consideration.

The differential diagnosis of right precordial ST-segment elevation is as follows^{[18, 29]}:

Atypical right bundle-branch block
Left ventricular hypertrophy
Early repolarization
Acute pericarditis
Acute myocardial ischemia or infarction
Prinzmetal angina
Pulmonary embolism
Dissecting aortic aneurysm
Mediastinal tumor or hemopericardium compressing the right ventricular outflow tract
Arrhythmogenic right ventricular dysplasia and/or cardiomyopathy
Various abnormalities of the central and autonomic nervous systems
Overdose of a heterocyclic antidepressant
Cocaine intoxication
Duchenne muscular dystrophy
Friedreich ataxia
Thiamine deficiency Hypercalcemia
Hyperkalemia
Hypothermia
Pectus excavatum
Effects of athletic training

Differential Diagnoses

Workup

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Media Gallery

Schematics show the 3 types of action potentials in the right ventricle: endocardial (End), mid myocardial (M), and epicardial (Epi). A, Normal situation on V2 ECG generated by transmural voltage gradients during the depolarization and repolarization phases of the action potential. B-E, Different alterations of the epicardial action potential that produce the ECG changes observed in patients with Brugada syndrome. Adapted from Antzelevitch, 2005.
Three types of ST-segment elevation in Brugada syndrome, as shown in the precordial leads on ECG in the same patient at different times. Left panel shows a type 1 ECG pattern with pronounced elevation of the J point (arrow), a coved-type ST segment, and an inverted T wave in V1 and V2. The middle panel illustrates a type 2 pattern with a saddleback ST-segment elevated by >1 mm. The right panel shows a type 3 pattern in which the ST segment is elevated < 1 mm. According to a consensus report (Antzelevitch, 2005), the type 1 ECG pattern is diagnostic of Brugada syndrome. Modified from Wilde, 2002. Image courtesy of Richard Nunez, MD, and EMedHome.com (http://www.emedhome.com/).

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Author

Jose M Dizon, MD Professor of Clinical Medicine, Clinical Electrophysiology Laboratory, Division of Cardiology, Columbia University College of Physicians and Surgeons; Attending Physician, Department of Medicine, New York-Presbyterian/Columbia University Medical Center

Jose M Dizon, MD is a member of the following medical societies: American College of Cardiology, Heart Rhythm Society

Disclosure: Nothing to disclose.

Coauthor(s)

Tamim M Nazif, MD Fellow, Division of Cardiology, Columbia University College of Physicians and Surgeons

Tamim M Nazif, MD is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ronald J Oudiz, MD, FACP, FACC, FCCP Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, American Thoracic Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Actelion, Bayer, Gilead, United Therapeutics<br/>Received research grant from: Actelion, Arena, Gilead, GSK, Liquidia, Reata, United Therapeutics<br/>Received income in an amount equal to or greater than $250 from: Actelion, Complexa, Gilead, Medtronic, Reata, United Therapeutics.

Chief Editor

Mikhael F El-Chami, MD Associate Professor, Department of Medicine, Division of Cardiology, Section of Electrophysiology, Emory University School of Medicine

Mikhael F El-Chami, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Heart Rhythm Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic; Boston Scientific, Biotronik<br/>Received research grants (as part of Multicenter studies) from Medtronic and Boston Scientific.

Additional Contributors

Justin D Pearlman, MD, ME, PhD, FACC, MA Chief, Division of Cardiology, Director of Cardiology Consultative Service, Director of Cardiology Clinic Service, Director of Cardiology Non-Invasive Laboratory, Chair of Institutional Review Board, University of California, Los Angeles, David Geffen School of Medicine

Justin D Pearlman, MD, ME, PhD, FACC, MA is a member of the following medical societies: American College of Cardiology, International Society for Magnetic Resonance in Medicine, American College of Physicians, American Federation for Medical Research, Radiological Society of North America

Disclosure: Nothing to disclose.

Characteristic	Type 1	Type 2	Type 3
J wave amplitude	≥2 mm	≥2 mm	≥2 mm
T wave	Negative	Positive or biphasic	Positive
ST-T configuration	Cove-type	Saddleback	Saddleback
ST segment, terminal portion	Gradually descending	Elevated by ≥1 mm	Elevated by < 1 mm

Brugada Syndrome Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

Contributor Information and Disclosures

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