Intended for healthcare professionals

Endgames Picture Quiz

A patient with chest pain and electrocardiographic changes

BMJ 2013; 347 doi: (Published 20 November 2013) Cite this as: BMJ 2013;347:f6839
  1. Jason Kwasi Sarfo-Annin, foundation year 2 doctor,
  2. Peter James Stafford, consultant cardiologist
  1. 1Glenfield Hospital, Department of Cardiology, Leicester LE3 9QP, UK
  1. Correspondence to: PJ Stafford peter.stafford{at}

A 33 year old white man was admitted to the local coronary care unit with chest pain. Two hours earlier he had developed epigastric pain, which evolved into central chest pain. There had been one episode of vomiting with dizziness, dyspnoea, sweating, and distal paraesthesiae. The pain had resolved by the time he was admitted to the unit.

Physical examination was normal; fig 1 shows the 12 lead electrocardiograph. Transthoracic echocardiography showed normal left ventricular systolic function, with no regional wall motion abnormalities, and normal valve function.

Fig 1 Twelve lead electrocardiograph on admission

Later that day he became nauseated, diaphoretic, and visibly pale. He also had blurred vision, muffled hearing, and tingling in both hands. Chest pain was not present. His systolic blood pressure had dropped to 89 mm Hg and bedside cardiac monitoring showed a pause of three to four seconds with no P wave activity, with a return of spontaneous QRS complexes. Subsequent physical examination was normal.

He later mentioned that his daughter currently had gastroenteritis and that he had been experiencing flu-like symptoms. He had a history of syncope with phlebotomy, but no other vasovagal-type events. His sister had been diagnosed with epilepsy with multiple seizures that were resistant to drugs.


  • 1 What condition do the history and admission electrocardiography suggest, and what is the immediate management?

  • 2 What are the next most appropriate investigations?

  • 3 How are patients with this condition risk stratified?

  • 4 What long term advice should patients be given?


1 What condition do the history and admission electrocardiograph suggest, and what is the immediate management?

Short answer

The electrocardiograph shows a “coved” type 1 Brugada pattern, which together with the patient’s history is suggestive of Brugada syndrome. Cardiac differential diagnoses include acute coronary syndromes and pericarditis in light of the syncope and fever. Chest pain could also originate from the respiratory system (for example, pulmonary embolus) or gastrointestinal tract …

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