Brugada Syndrome

Subscribe to Resus

Get the latest updates on our Conferences PLUS our Webcasts and Education Newsletters. And it's FREE!

  • We respect your privacy
  • This field is for validation purposes and should be left unchanged.

Register Now:

Learn More

A 25 year old male presents to the emergency department following a near syncopal episode. His ECG shows a supraventricular tachycardia(SVT). Vagal manoeuvres are attempted, unsuccessfully. Adenosine is then given for reversion. He reverts and his post-reversion ECG is shown below. One of the registrars is concerned that the ECG is showing a Brugada pattern.

Is this right? Is this a Brugada Pattern and has the patient demonstrated Brugada Syndrome? Do patients with Brugada even present with an SVT?

How do we make the diagnosis and what do we look for in the ECG? Brugada is one of the ECG’s of Syncope, that we cover in the Cardiac Bootcamp.

SVT in patient with pre-syncope

Post Adenosine

What is Brugada Syndrome?

It is an inherited autosomal dominant Na+ channel abnormality(1). It is far more common in males (by factor of 8-10:1) where it is the second most common cause of death in those less than 40 years of age. The true prevalence is difficult to estimate, as it is a dynamic ECG pattern, ie., it is not always present. It is usually associated with sudden death in those with structurally normal hearts.

It’s prevalence is about 5/10000 of the population, being responsible for approximately 4% of all sudden cardiac deaths. It has a high prevalence in South-East Asia and is the same disorder as the previously known Sudden Unexplained Nocturnal Death Syndrome(SUNDS)(2)

Patients may suffer sudden cardiac death, or present in cardiac arrest, usually with polymorphic ventricular tachycardia or ventricular fibrillation(VF) being the most common arrhythmias. Patients with the syndrome, may also present following a syncopal episode, which may be a result of self-termination of the arrhythmia.

Beware the patient whose partner or family member describe nocturnal agonal respirations, as  VF and sudden death in Brugada usually occurs at night or at rest(2). This may be due to sympathovagal balance or bradycardia which may initiate the arrhythmia.




The high prevalence in Asian populations has seen specific language emerge to  describe it’s occurrence at night(3):

  1. In Thailand, ‘Lai Tai’ was the term used to describe nocturnal deaths. The word “Lai” means a loud groan occurring in sleep  and “Tai” means death.
  2. In the Philippines Bangungut, means “to rise and moan in sleep,” and describes the disease.
  3. In Japan, Pokkuri Death Syndrome, was similar, with “Pokkuri” meaning sudden, unexpected death.

Making the Diagnosis

The diagnosis is made when both:

  1. The diagnostic Brugada ECG pattern is present and
  2. There is a relevant clinical history.

ECG Findings in Brugada Syndrome

The changes seen on ECG, known as the Brugada pattern may be concealed, intermittent or dynamic, probably secondary to the Na+ channel dysfunction being affected by several factors.

The pattern is more likely to be seen in the following circumstances:

  1. Fever
  2. Intoxication
  3. Vagal Stimulation
  4. Electrolyte abnormality ; hyper/hypo K+, hyperCa2+
  5. Unmasked by Na+ channel blockers
  6. Medication related:
    1. Alpha agonists
    2. Beta blockers
    3. Tricyclic/tetracyclic antidepressants
    4. Antianginals
  7. Drug related: Cocaine toxicity
  8. Ischaemia
  9. Cardioversion: The ECG feature Type I pattern, can appear for a short period after cardioversion, although the significance of this is uncertain(4)

The important ECG patterns occur mostly in the right sided leads ie V1-V2 as the zone most affected is at the right ventricular outflow tract(RVOT)

These changes seen in leads V1 or V2 or both are shown below.

ECG Patterns

TYPE I: Coved Pattern

This is a very specific pattern and in patients with no heart disease is highly specific for Brugada.




The important elements of the pattern are:

It has a concave or rectilinear pattern in V1 or V2

There is an upslope of usually greater than 2mm at the end of the QRS

RBBB vs Coved pattern




Unlike right bundle branch block(RBBB), the downslope curve remains raised above the isoelectric line, far longer in the Brugada pattern. If we take a point 80ms(2 small squares) from the high take off, the curve is still raised above the isoelectric line, whereas in RBBB it would be at a far lower point, as shown above.

TYPE II: Saddle-back pattern

This pattern combines the previous Type II and III patterns into a new Type II pattern.

There must be an RSr’ pattern with a saddle-back morphology. The r’ is usually more than 2mm above the isoelectric line.

The QRS duration in Brugada is greater in V1 than V6. This helps distinguish it from a RBBB where the QRS duration is similar in both these leads.

This morphology can be a normal finding on ECGs. To distinguish a normal morphology from a saddle-back pattern  of Brugada we need to calculate the beta angle as shown below. A wide beta angle (> 35 degrees) indicates a Brugada pattern.

Is this Type II pattern really Brugada?

Draw a Horizontal line across the top of the r’ and a line 5mm below this

Then draw a line along the descending arm of r’

If the length of the base of the triangle is >3.5mm, this equates to a beta angle of >35 degrees and confirms that this is Brugada

Now let’s revisit the example above where the patient was reverted with Adenosine.

Is this Brugada?

Draw the necessary lines as in the previous example

The beta angle is less than 35 degrees (base <3.5mm) so this is not Brugada

If there is a suggestion of a Brugada pattern in V1-V2, a further ecg should be performed with high precordial leads as shown. This simply means moving the leads V1 and V2 from the 4th intercostal spaces to the second or third. This allows the leads to be closer to the affected zone, which usually coincides with the RVOT and unmask the abnormality. We are looking for the Type I coved pattern to be unmasked in these high precordial leads.

Beware, that a false Type II Saddleback pattern can occur, if the V1 and V2 leads are placed too high. A clue to their misplacement is given by the P wave in V2. This should normally be upright. If it is not, then be suspicious of high leads and redo the ECG.

Clinical Criteria

To make the diagnosis of Brugada Syndrome we need both the ECG patterns described above and the clinical features that may give us a clue to the syndrome, being present. These include:

  1. Survivor of cardiac arrest
  2. Presence of polymorphic VT or VF
  3. Hisptory of non-vagal syncope
  4. Familial history of sudden death in less than 45 yo with no acute coronary syndrome
  5. Type I coved pattern in relatives

Other things that may assist us are the inducibility of VT with electrical stimulation.

Other things to consider

Brugada Phenocopies

There are so called Brugada phenocopies, which are Brugada patterns arising from various causes which can include:

  • Metabolic disorders
  • Electrocution
  • Ischaemia
  • Cardioversion, which usually resolve on resolution of the injury. Their prognosis is unknown.

Supraventricular arrhythmias in Brugada

  • 20% of patients with Brugada develop supraventricular arrhythmias.(5).Up to 20% of cases have atrial fibrillation. Atrioventricular nodal re-entry tachycardia and Wolff-Parkinson White Syndrome have also been described(5)

Risk Stratification of patients

The only proven therapy for these patients is an implantable defibrillator.(6) In the acute setting, we need to discuss all these patients with cardiology. However only those patients with a typical ECG pattern and clinical criteria will need admission

Those with a type I pattern, should all be admitted as they have a significant risk of mortality. An incidental finding of this pattern does predict a lower risk of mortality. One approach is shown below.

Bayes de Luna A et al. J of Electrocardiology 45(2012)433-442


  1. Bayes de Luna A et al. Current electrocardiographic criteria for diagnosis of Brugada pattern: a concensus report. J of Electrocardiology 45;(2012)432-442
  2. Antzeleviteh C et al. Brugada Syndrome. Report of the second Concensus conference. Circulation 2005;111:659-670.
  3. Zheng J et al. Sudden Unexplained Nocturnal Death Syndrome:The Hundred Years’ Enigma. JAHA March 6 2018, Vol7:5 pp
  4. Kok LC et al. Transient ST elevation after transthoracic cardioversion in patients with haemodynamically unstable ventricular arrhythmias. Am J Cardiol. 2000;85:878-881.
  5. Morita H et al. Atrial fibrillation and atrial vulnerability in patients with Brugada Syndrome. J Am Coll Cardiol 2002;40:1437-1444
  6. Exkardt L et al. Wolff-Parkinson-White syndrome associated with Brugada Syndrome. Pacimg Cin Electrophysiology. 2001;24:1421-1424.
  7. Brugada J et al. Long term followup of individuals with electrocardiographic pattern of right bundle branch block and St segment elevation in precordial leads V1-V3. Circulation 2002;105:73-78.

Peter Kas


Dr Peter Kas

Emergency Physician, Educator. Key Interests: Resuscitation, Airway, Emergency Cardiology, Clinical Examination. Creator


  1. Bulk Private Proxies on 13/09/2021 at 1:02 pm

    Definitely, what a magnificent website and informative posts, I will bookmark your site.Have an awsome day!

  2. Rae on 17/09/2021 at 10:27 am

    I all the time used to study piece of writing in news papers but now as I
    am a user of internet therefore from now I
    am using net for articles or reviews, thanks to web.

  3. Mega Male Enhancement Review on 17/09/2021 at 10:28 am

    You could definitely see your enthusiasm in the work you write.
    The sector hopes for even more passionate writers such as
    you who aren’t afraid to mention how they believe.

    At all times go after your heart.

    Also visit my blog post … Mega Male Enhancement Review

  4. Extreme Keto EFX Review on 17/09/2021 at 10:34 am

    I love the efforts you have put in this, regards for all the great content.

    Here is my blog post: Extreme Keto EFX Review

  5. Max Melt Keto Ingredients on 17/09/2021 at 10:35 am

    It?s hard to find educated people on this topic,
    however, you seem like you know what you?re talking about!


    Have a look at my webpage … Max Melt Keto Ingredients

  6. on 17/09/2021 at 10:45 am

    Its excellent as your other blog posts :D, appreciate it for putting up.

    My homepage :: Erectesto XL Reviews (

  7. Max Melt Keto Ingredients on 17/09/2021 at 10:55 am

    Fantastic goods from you, man. I’ve understand your stuff previous to and you’re just
    extremely magnificent. I really like what you have acquired here, really like what you’re saying and the way in which you say
    it. You make it enjoyable and you still take care of to keep it smart.
    I can not wait to read far more from you. This is really a great website.

    Look into my website – Max Melt Keto Ingredients

  8. Awesome blog! Is your theme custom made or did you download
    it from somewhere? A theme like yours with a few simple tweeks would really make my blog jump out.
    Please let me know where you got your design. Cheers

    Look at my blog post; A1 Keto BHB Ingredients (

  9. UltraXTend on 17/09/2021 at 10:57 am

    Hello! This post could not be written any better!
    Reading through this post reminds me of my good old room mate!
    He always kept talking about this. I will forward this post to him.
    Fairly certain he will have a good read. Thank you for sharing!

    My homepage … UltraXTend

  10. Pure CBD Softgels Review on 17/09/2021 at 11:15 am

    I am impressed with this web site, very I am a big fan.

    my homepage – Pure CBD Softgels Review

  11. GrownMD CBD Reviews on 17/09/2021 at 11:26 am

    As a Newbie, I am permanently browsing online for articles
    that can aid me. Thank you

    my blog post: GrownMD CBD Reviews

  12. Terra Xtract CBD Review on 17/09/2021 at 11:32 am

    I likewise believe therefore, perfectly composed post!

    Feel free to visit my page – Terra Xtract CBD Review

  13. Excellent way of explaining, and good article to obtain information regarding my presentation topic, which i am going
    to convey in academy.

    my web site :: Keto-X3 (

  14. on 17/09/2021 at 11:49 am

    Excellent, what a weblog it is! This blog gives helpful data to us, keep it up.

  15. TestoXmen Ingredients on 17/09/2021 at 12:10 pm

    Wow! This can be one particular of the most useful blogs We have ever arrive across on this subject.
    Basically Great. I am also a specialist in this topic so I can understand your hard work.

    Feel free to visit my webpage TestoXmen Ingredients

  16. Pure CBD Softgels Cost on 17/09/2021 at 12:14 pm

    Appreciate this post. Let me try it out.

    Also visit my homepage: Pure CBD Softgels Cost

  17. on 17/09/2021 at 12:24 pm

    Keep up the fantastic piece of work, I read few blog posts on this web site
    and I believe that your blog is really interesting and contains sets of excellent info.

    Feel free to surf to my web-site; Ultra Quick Keto (

  18. on 17/09/2021 at 12:32 pm

    Exceptional post however , I was wondering if you could write a litte more on this subject?
    I’d be very thankful if you could elaborate a little bit more.

    Bless you!

  19. on 17/09/2021 at 12:36 pm

    Everything is very open with a very clear explanation of the challenges.
    It was really informative. Your site is useful.
    Many thanks for sharing!

  20. Ultra Quick Keto Burn on 17/09/2021 at 12:45 pm

    First-class info it is without doubt. My teacher has been looking for this update.

    Also visit my web blog Ultra Quick Keto Burn

  21. Renew Brite Review on 17/09/2021 at 12:51 pm

    Great delivery. Solid arguments. Keep up the amazing work.

    Visit my web page Renew Brite Review

  22. GrownMD CBD Gummies on 17/09/2021 at 12:59 pm

    Aw, this was a really nice post. Finding the time and actual
    effort to make a very good article… but what can I say…
    I put things off a lot and never manage to get nearly
    anything done.

    Feel free to visit my site GrownMD CBD Gummies

  23. Mega Male Enhancement Pills on 17/09/2021 at 1:09 pm

    These are in fact great ideas in concerning blogging. You have touched some pleasant factors here.
    Any way keep up wrinting.

    Feel free to visit my webpage: Mega Male Enhancement Pills

  24. on 17/09/2021 at 1:18 pm

    Hi, everything is going fine here and ofcourse every one is sharing facts,
    that’s genuinely good, keep up writing.

    Here is my website :: Bioneo Farms CBD –

  25. Tundra Breeze Portable AC Review on 17/09/2021 at 1:20 pm

    Hi, i think that i saw you visited my website so i came to ?return the favor?.I’m trying to find things to enhance my web site!I suppose its ok to use some
    of your ideas!!

    Here is my web page Tundra Breeze Portable AC Review

  26. Quick Keto Trim Pills on 17/09/2021 at 1:28 pm

    An intriguing discussion is definitely worth comment.
    I do think that you should publish more on this subject, it may not be a taboo subject
    but generally folks don’t talk about such subjects.
    To the next! Many thanks!!

    Look at my page; Quick Keto Trim Pills

  27. on 17/09/2021 at 1:29 pm

    I as well think so, perfectly written post!

    Here is my website Erectesto XL Pills (

  28. Elizbeth on 17/09/2021 at 3:20 pm

    Hi there to every body, it’s my first pay a quick visit of this webpage; this
    blog carries awesome and in fact fine stuff in favor of readers.

  29. Bioneo Farms CBD Reviews on 17/09/2021 at 3:52 pm

    This is a topic which is close to my heart… Thank you! Exactly where are your
    contact details though?

    Feel free to visit my web site: Bioneo Farms CBD Reviews

  30. Extreme Muscle XXL Reviews on 17/09/2021 at 4:15 pm

    Oh my goodness! Awesome article dude! Thank you, However I am experiencing problems with your RSS.
    I don’t know the reason why I can’t subscribe to it.
    Is there anybody else having the same RSS issues? Anybody who knows the solution will you kindly respond?

    my page: Extreme Muscle XXL Reviews

  31. xì dách in english on 17/09/2021 at 4:38 pm

    Whoa! This blog looks exactly like my old one! It’s on a totally different subject but it has pretty
    much the same layout and design. Great choice of colors!

  32. Extreme Keto EFX Reviews on 17/09/2021 at 5:59 pm

    Hi, all the time i used to check blog posts here early in the break of day, for
    the reason that i enjoy to find out more and more.

    Also visit my web site – Extreme Keto EFX Reviews

  33. Carlos on 17/09/2021 at 6:08 pm

    bookmarked!!, I really like your web site!

  34. Marta on 18/09/2021 at 4:13 pm

    Wow, this article is nice, my sister is analyzing these things, so I am going to convey her.

  35. Aidan on 19/09/2021 at 7:57 pm

    I’m not sure exactly why but this site is loading very slow
    for me. Is anyone else having this issue or is it
    a problem on my end? I’ll check back later and see if the problem still exists.

  36. Baccarat Png on 19/09/2021 at 11:40 pm

    My partmer and I stumbled over here from a differentt website and thought I might as well check things out.
    I like hat I see so nnow i’m following you. Look forwward to finding out about yohr web page
    for a second time.

    Also visit my page – Baccarat Png

  37. Lucy on 20/09/2021 at 1:55 am

    Today, I went to the beachfront with my kids. I found a
    sea shell and gave it to my 4 year old daughter and said “You can hear the ocean if you put this to your ear.” She placed the shell to her
    ear and screamed. There was a hermit crab inside and it pinched
    her ear. She never wants to go back! LoL I know this is totally off topic but I had to tell someone!

Leave a Comment