This 45-year-old man presents to the Emergency Department with atypical chest pain for the past two hours. He reports occasional palpitations, usually at night, subsiding spontaneously after 15-30 minutes. He reports having a good exercise tolerance:

• rSr’ and ST elevation in V1 and V2
• Consider Brugada pattern (type 2)

His cardiac enzymes were borderline elevated. The patient was referred to cardiac catheterization lab. Coronary angiograms were normal, and the patient was discharged and referred to the EP Clinic.

The patient is seen in the EP clinic 4 months later. He has experienced no further chest pain, but endorses occasional palpitations, mostly in the evening or at night:

• Sinus rhythm 67/min
• ST elevation in V1 and V2
• Consider Brugada pattern (type 2)

In view of the history of palpitations, the patient undergoes an EP study, with an attempt to induce VT, and a Procainamide challenge. An arrhythmia can not be induced, however the following ECG is recorded during the procainamide infusion (procainamide challenge test):

• Sinus rhythm
• Brugada pattern (type 2 changes to type 1)
• A positive Procainamide challenge test

{tab= ECG #4}

The patient is seen for follow-up in the EP clinic 2 months later. He reports that his palpitations are infrequent and not accompanied by symptoms that might suggest ventricular arrhythmias. His family history is negative for sudden death or arrhythmias. He is referred to his family MD for regular follow-up:

• Sinus rhythm
• ST elevation in V1 and V2 (no longer meeting criteria for Brugada pattern)

Comment: These ECGs highlight the varying nature of the ECG in patients with Brugada pattern