Case report
Brugada pattern in a patient medicated with lamotrigine
Padrão de Brugada em doente medicada com lamotrigina
Rita Rodrigues
, Pedro Amador, Leandro Rassi, Filipe Seixo, Leonor Parreira, Nuno Fonseca, Luís Soares
Corresponding author
Serviço de Cardiologia, Centro Hospitalar de Setúbal, EPE - Hospital de São Bernardo, Setúbal, Portugal
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A) Derivações V1 e V2 no quarto espaço intercostal, sem administração de flecainida. B) Derivações V1 e V2 no segundo espaço intercostal, sem administração de flecainida. C) Derivações V1 e V2 no quarto espaço intercostal, após a administração de flecainida D) Derivações V1 e V2 no segundo espaço intercostal, após a administração de flecainida, com supradesnivelamento de 2<span class="elsevierStyleHsp" style=""></span>mm do segmento ST em rampa descendente e onda T negativa simétrica – padrão de Brugada tipo 1.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Rita Rodrigues, Pedro Amador, Leandro Rassi, Filipe Seixo, Leonor Parreira, Nuno Fonseca, Luís Soares" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Rita" "apellidos" => "Rodrigues" ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "Amador" ] 2 => array:2 [ "nombre" => "Leandro" "apellidos" => "Rassi" ] 3 => array:2 [ "nombre" => "Filipe" "apellidos" => "Seixo" ] 4 => array:2 [ "nombre" => "Leonor" "apellidos" => "Parreira" ] 5 => array:2 [ "nombre" => "Nuno" "apellidos" => "Fonseca" ] 6 => array:2 [ "nombre" => "Luís" "apellidos" => "Soares" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204913001852" "doi" => "10.1016/j.repce.2013.10.020" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001852?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113001662?idApp=UINPBA00004E" "url" => "/08702551/0000003200000010/v1_201311090028/S0870255113001662/v1_201311090028/pt/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2174204913002304" "issn" => "21742049" "doi" => "10.1016/j.repce.2013.02.013" "estado" => "S300" "fechaPublicacion" => "2013-10-01" "aid" => "340" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2013;32:811-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 7213 "formatos" => array:3 [ "EPUB" => 185 "HTML" => 6220 "PDF" => 808 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Coronary artery perforations: Four different cases and a review" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "811" "paginaFinal" => "815" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Perfurações de artérias coronárias: quatro casos diferentes e uma revisão" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 809 "Ancho" => 2502 "Tamanyo" => 155126 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A long, calcified, and eccentric critical lesion in the mid to distal left anterior descending coronary artery (A); type II perforation showing limited extravasation with some myocardial blushing (B); no myocardial blushing is seen on the control angiogram after covered stenting (C).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ismail Dogu Kilic, Yusuf Izzettin Alihanoglu, Serhat B. 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Hospital de São Bernardo, Setúbal, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Padrão de Brugada em doente medicada com lamotrigina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1312 "Ancho" => 1549 "Tamanyo" => 420742 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ECGs performed during the first flecainide test, with the patient medicated with lamotrigine: (A) leads V1 and V2 over the fourth intercostal space, before administration of flecainide; (B) leads V1 and V2 over the second intercostal space, before administration of flecainide; (C) leads V1 and V2 over the fourth intercostal space, after administration of flecainide; (D) leads V1 and V2 over the second intercostal space, after administration of flecainide, with 2-mm downsloping ST-segment elevation and negative T waves – type 1 Brugada pattern.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Brugada syndrome is a genetic heart disease, autosomal dominant in 50% of cases, which can be caused by over 70 possible mutations, a mutation in the <span class="elsevierStyleItalic">SCN5A</span> gene being found in 20% of patients. It is most common in young men and usually results from accelerated inactivation of sodium channels in heart cell membranes.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Diagnosis is based on clinical and electrocardiographic criteria. Patients normally have a history of syncope or sudden death, due to malignant arrhythmias such as ventricular fibrillation or ventricular tachycardia. There may also be a history of sudden death in young relatives.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> Two types of typical electrocardiographic patterns in leads V1-V3 are observed: type 1, more specific, with gradually downsloping ST-segment elevation of ≥2 mm, coved-type or horizontal in relation to the isoelectric line, with a symmetrical negative T wave; and type 2, with R-wave amplitude of ≥2 mm in relation to the isoelectric line, followed by ST elevation of at least 0.05 mV, with positive T waves in V2 and variable T waves in V1.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Brugada ECG pattern can be intermittent and may be observed only in certain situations, such as fever, intoxication, vagal stimulation, electrolyte imbalance, acute myocardial ischemia, pericarditis or myocarditis, or be triggered by certain drugs, particularly sodium channel blockers. This pattern, which may arise from multiple causes and disappear once the cause has been rectified, is termed Brugada phenocopy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors describe the case of a 52-year-old woman, with a history of hypertension, dyslipidemia and depressive syndrome, treated with lamotrigine 100 mg for about five months. There was no relevant family history. The patient went to the emergency department for atypical precordial pain (sharp, non-radiating). The admission electrocardiogram (ECG) showed 2-mm downsloping ST-segment elevation in V1 and V2 and negative T waves (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). This setting in a patient with cardiovascular risk factors was interpreted as myocardial infarction but cardiac catheterization showed normal coronary arteries.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Following exclusion of infarction requiring urgent intervention, it was noted that the admission ECG was suggestive of type 1 Brugada pattern. There was no history of syncope and the echocardiogram was normal. Subsequent serial ECGs were less typical, and so a flecainide test was performed. ECGs with leads V1 and V2 positioned successively over the fourth, third and second intercostal spaces were performed before administration of the sodium channel blocker. Flecainide was then administered, the dose adjusted to the patient's weight, followed by ECGs with leads V1 and V2 positioned successively over the fourth, third and second intercostal spaces. All ECGs before administration of flecainide (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A and B) and those performed with leads V1 and V2 over the fourth (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>C) and third intercostal spaces after administration of the drug showed no typical Brugada pattern; however, the ECG with leads V1 and V2 over the second intercostal space did show type 1 Brugada pattern (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>D) following administration of flecainide.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The link between various psychoactive drugs and malignant arrhythmias in Brugada syndrome and type 1 Brugada phenocopy is well known. Lamotrigine is a sodium channel blocker, as are class I antiarrhythmic drugs such as flecainide. The possibility was therefore considered that lamotrigine could have triggered the Brugada pattern, and the drug was discontinued.</p><p id="par0035" class="elsevierStylePara elsevierViewall">When the patient was observed again around two weeks after discontinuation of lamotrigine, she was asymptomatic, medicated with topiramate 25 mg. A further flecainide test was performed using the same protocol, and no type 1 Brugada pattern was observed on any ECG, including that with leads V1 and V2 over the second intercostal space after administration of the drug (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Various psychoactive drugs such as lithium, amitriptyline, nortriptyline, oxcarbazepine and clomipramine are contraindicated in patients with Brugada syndrome as they are associated with malignant arrhythmias, syncope and sudden death.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Class I antiarrhythmic drugs, including flecainide, propafenone, procainamide, ajmaline and pilsicainide, which inhibit the beginning of the cardiac action potential by blocking sodium channels, are also contraindicated in Brugada syndrome for the same reason.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Lamotrigine is not contraindicated in Brugada patients, but it acts through blocking voltage-dependent sodium channels in the cerebral cortex, thereby inhibiting the release of neurotransmitters.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,7</span></a> It is thus a potential trigger of type 1 Brugada pattern.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In some cases, the pattern is only evident in the upper precordial leads (V1 and V2 in the second or third intercostal spaces) since abnormal electrical activity is confined to the area of the right ventricular outflow tract. This is the principle behind the flecainide test.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">The case presented describes a female patient with type 1 Brugada pattern on ECG triggered by lamotrigine, which is not currently contraindicated in Brugada syndrome. The drug was discontinued due to the risk of malignant arrhythmias. However, the situation would not have been identified without knowledge of the drug's mechanism of action and of the pathophysiology of the Brugada pattern, for which the flecainide test played a fundamental role.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The case highlights the importance of familiarity with how drugs act and alertness to their potential secondary effects, which were crucial to correct diagnosis in this patient.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres298803" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec281826" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres298802" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec281827" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-12-23" "fechaAceptado" => "2013-01-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec281826" "palabras" => array:6 [ 0 => "Brugada pattern" 1 => "Brugada syndrome" 2 => "Phenocopy" 3 => "Lamotrigine" 4 => "Flecainide test" 5 => "Electrocardiogram" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec281827" "palabras" => array:6 [ 0 => "Padrão de Brugada" 1 => "Síndrome de Brugada" 2 => "Fenocópia" 3 => "Lamotrigina" 4 => "Teste de flecainida" 5 => "Eletrocardiograma" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The authors report the case of a 52-year-old woman with depressive syndrome, treated with lamotrigine for about five months, who went to the emergency department for atypical precordial pain. The electrocardiogram (ECG) revealed a 2-mm downsloping ST-segment elevation and negative T waves in V1 and V2. Due to suspicion of ST-elevation acute coronary syndrome, cardiac catheterization was performed, which revealed normal coronary arteries. The initial ECG was suggestive of type 1 Brugada pattern, but subsequent serial ECGs were less typical. A flecainide test showed the same pattern.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">After discontinuation of lamotrigine reversal of the typical Brugada ECG pattern was observed.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Although not currently contraindicated in Brugada syndrome, the antidepressant lamotrigine blocks sodium channels, which are usually inactivated in heart cell membranes in Brugada syndrome, and may be responsible for the expression of type 1 Brugada pattern.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Os autores relatam o caso de uma mulher de 52 anos com síndrome depressiva, medicada com lamotrigina há cerca de cinco meses, que recorre à urgência por dor pré-cordial atípica. Realizou eletrocardiograma (ECG) que revelou supradesnivelamento do segmento ST de 2 mm, em rampa descendente, e onda T negativa em V1 e V2. Por suspeita de síndrome coronária aguda com supradesnivelamento de ST, a doente efetuou cateterismo que revelou coronárias normais. O ECG da entrada era sugestivo de padrão de Brugada tipo 1, mas os ECG seriados eram menos típicos, tendo-se realizado o teste de flecainida, onde se objetivou o mesmo padrão.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Com a interrupção da lamotrigina, houve reversão do padrão eletrocardiográfico típico de Brugada.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Apesar de não estar atualmente contraindicada na síndrome de Brugada, a lamotrigina é um antidepressivo que bloqueia canais de sódio, normalmente inativados na membrana das células cardíacas na síndrome de Brugada, podendo ser responsável por manifestação de padrão de Brugada tipo 1.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodrigues R, Amador P, Rassi L, et al. Padrão de Brugada em doente medicada com lamotrigina. Rev Port Cardiol. 2013;32:807–810.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 836 "Ancho" => 1860 "Tamanyo" => 270768 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">ECG on admission to the emergency department, showing 2-mm downsloping ST-segment elevation in V1 and V2 and symmetrical negative T waves – type 1 Brugada pattern.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1312 "Ancho" => 1549 "Tamanyo" => 420742 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">ECGs performed during the first flecainide test, with the patient medicated with lamotrigine: (A) leads V1 and V2 over the fourth intercostal space, before administration of flecainide; (B) leads V1 and V2 over the second intercostal space, before administration of flecainide; (C) leads V1 and V2 over the fourth intercostal space, after administration of flecainide; (D) leads V1 and V2 over the second intercostal space, after administration of flecainide, with 2-mm downsloping ST-segment elevation and negative T waves – type 1 Brugada pattern.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 786 "Ancho" => 1033 "Tamanyo" => 285738 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ECG performed during the second flecainide test following discontinuation of lamotrigine, with leads V1 and V2 over the second intercostal space after administration of flecainide – negative for type 1 Brugada pattern.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current electrocardiographic criteria for diagnosis of Brugada pattern: A consensus report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 2 | 17 |
| 2024 October | 79 | 44 | 123 |
| 2024 September | 94 | 27 | 121 |
| 2024 August | 80 | 34 | 114 |
| 2024 July | 61 | 31 | 92 |
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| 2018 July | 31 | 5 | 36 |
| 2018 June | 48 | 6 | 54 |
| 2018 May | 53 | 10 | 63 |
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| 2018 March | 76 | 9 | 85 |
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| 2017 April | 49 | 5 | 54 |
| 2017 March | 36 | 12 | 48 |
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| 2016 December | 76 | 21 | 97 |
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| 2016 September | 29 | 10 | 39 |
| 2016 August | 5 | 3 | 8 |
| 2016 July | 16 | 3 | 19 |
| 2016 June | 16 | 9 | 25 |
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| 2016 April | 41 | 2 | 43 |
| 2016 March | 83 | 21 | 104 |
| 2016 February | 93 | 32 | 125 |
| 2016 January | 78 | 24 | 102 |
| 2015 December | 62 | 13 | 75 |
| 2015 November | 66 | 18 | 84 |
| 2015 October | 74 | 20 | 94 |
| 2015 September | 69 | 26 | 95 |
| 2015 August | 62 | 18 | 80 |
| 2015 July | 61 | 9 | 70 |
| 2015 June | 44 | 1 | 45 |
| 2015 May | 54 | 13 | 67 |
| 2015 April | 57 | 30 | 87 |
| 2015 March | 63 | 16 | 79 |
| 2015 February | 60 | 14 | 74 |
| 2015 January | 88 | 14 | 102 |
| 2014 December | 128 | 27 | 155 |
| 2014 November | 114 | 22 | 136 |
| 2014 October | 126 | 18 | 144 |
| 2014 September | 99 | 33 | 132 |
| 2014 August | 151 | 19 | 170 |
| 2014 July | 108 | 14 | 122 |
| 2014 June | 66 | 15 | 81 |
| 2014 May | 73 | 16 | 89 |
| 2014 April | 55 | 23 | 78 |
| 2014 March | 77 | 26 | 103 |
| 2014 February | 65 | 31 | 96 |
| 2014 January | 84 | 29 | 113 |
| 2013 December | 33 | 11 | 44 |
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