[Normal conventional electrocardiogram with negative pharmacological stress test does not rule out Brugada syndrome]

The diagnosis of Brugada syndrome, or right bundle-branch block with an elevated ST segment and negative T waves in V1-3, is obscured by the transitory normalization of the electrocardiogram, which can be unmasked by administering sodium-channel blockers. It has been recently reported that the condition can be underdiagnosed if only conventional precordial leads are used. We present the cases of two asymptomatic patients, a mother and son, with a family history of sudden cardiac death in first-degree relatives. Baseline ECGs obtained in conventional leads and one and two intercostal spaces above conventional electrode sites were similar, normal in the mother and saddle-like in the son. A flecainide stress test elicited the characteristic pattern of Brugada syndrome in both patients, but only in the high leads. Pharmacological stress testing with conventional precordial lead recordings does not rule out Brugada syndrome. We recommend that ECG recordings should include leads in the second and third intercostal spaces.