[Recurrent syncope in a 34-year-old woman triathlete]

Some weeks previously a 34-year old athlete, specializing in the triathlon, had 6 syncopes in one day. They had caused abrasions and contusions resulting from the falls. At another hospital paroxysmal atrial fibrillation had been diagnosed and treatment with disopyramide (2 x 200 mg) initiated, but she had about 15 further syncopes within 2 weeks. She was admitted for establishing their cause.

Initial ECGs and neurological examination failed to provide a diagnosis and she was discharged with an "event recorder".

Three weeks after discharge she had another syncope. The event recorder was activated by the patient's partner and revealed polymorphous ventricular tachycardia. She underwent extensive invasive cardiological tests, including a right ventricular biopsy, but no abnormality was demonstrated. However, a provocation test with ajmaline produced ST segment elevations in V1 and V2 typical of the syndrome previously described by the Brugadas (right bundle branch block, precordial ST elevations in V1-V3 and sudden cardiac death). A cardioverter-defibrillator was implanted. During the subsequent observation period of 2 month the ICD delivered one countershock, triggered by the onset of polymorphous ventricular tachycardia with syncope.

In patients with serious ventricular arrhythmias but no diagnostic findings, including a normal resting ECG, a drug provocation test should be performed to exclude a Brugada syndrome.