Answer
Out-of-hospital electrocardiogram (ECG) shows a sinus rhythm of 85 beats per minute (bpm), narrow QRS complex, and ST-segment elevations in leads V1–V4 (coved morphology in V1–V2), with a terminal negative T wave in V1–V2 (Fig. 1). ECG findings could be suspicious for acute anteroseptal myocardial infarction, but reciprocal ST-segment changes are lacking. The ECG is also suggestive of a coved-type Brugada-like pattern, and the patient had no history of syncope or any other cardiac symptom, nor a family history of unexplained sudden cardiac death.
The patient met criteria for exertional heat stroke [1], and was admitted to the intensive care unit for rhythm monitoring. Fluid therapy was started, and within the first 2 hours the ECG showed sinus bradycardia of 48 bpm, normalised ST segment, QTc of 430 ms, and prominent U waves in V2–V3 (Fig. 2), remaining with similar features during the hospital stay. Echocardiogram and computed tomography coronary angiography performed before discharge were normal.
Diffuse ST-T deviations have been described in patients with heat stroke [2], but right precordial leads ST elevation suggestive of Brugada pattern in this context is exceptional [3]. Ion channels sensitive to temperature may explain this electrocardiographic finding in susceptible individuals. In the present case, the rapid resolution of ECG abnormalities favours the diagnosis of Brugada-like ECG pattern induced by exertional heat stroke, and a negative ajmaline provocation test reinforces the diagnosis.
Conclusion
Type 1 Brugada-like ECG pattern induced by exertional heat stroke.
References
Hifumi T, Kondo Y, Shimizu K, Miyake Y. Heat stroke. J Intensive Care. 2018;6:30.
Mimish L. Electrocardiographic findings in heat stroke and exhaustion: A study on Makkah pilgrims. J Saudi Heart Assoc. 2012;24:35–9.
Lacunza J, San Román I, Moreno S, et al. Heat stroke, an unusual trigger of Brugada electrocardiogram. Am J Emerg Med. 2009;27:634.e1–634.e3.
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L.E. Lezcano Gort, B. Roque Rodríguez and M.R. Porro Fernández declare that they have no competing interests.
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Lezcano Gort, L.E., Roque Rodríguez, B. & Porro Fernández, M.R. A young man with exertional chest discomfort. Neth Heart J 27, 284–285 (2019). https://doi.org/10.1007/s12471-019-1276-8
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DOI: https://doi.org/10.1007/s12471-019-1276-8