This 69-year-old man is admitted after a nocturnal episode of loss of consciousness and seizures, that was witnessed by his wife. He was pale, pulseless and stopped breathing. His wife started CPR and called 911. When the ambulance came he had recovered consciousness and no arrhythmia was documented. He had suffered from two similar episodes 5 and 3 months before. In hospital the serum troponin level is transiently elevated to 2.03. Non-invasive functional cardiac studies, echocardiogram and coronary angiography are normal.

• Sinus rhythm
• Incomplete right bundle branch block (iRBBB) pattern with ST elevation in V1 to V3
• ECG findings suggestive of Brugada pattern

The patient undergoes electro-physiologic (EP) studies. Ventricular tachycardia could not be induced by programmed ventricular stimulation. As the J-point elevation in V1 and V2 in the hospital admission ECGs was minimal, a procainamide challenge test is carried out. This ECG is recorded during the test.

• Procainamide challenge test clearly positive for Brugada pattern
• Right bundle branch block with type 1 Brugada (“coved pattern”) significant ST elevation in V1 to V3.

Comment: In view of the recent episodes of loss of consciousness with seizures, implantation of an ICD (Implantable Cardioverter Defibrillator) was strongly advised.

This ECG is recorded 4 hours after the end of the procainamide challenge:

• Sinus rhythm
• Compared with the previous tracing, the ECG changes of Brugada pattern are no longer present. 

Comment: This case highlights the varying nature of the ECG in patients with Brugada pattern