A Practical Approach to the Investigation of an rSr’ Pattern in Leads V1-V2

The “rSr′ ECG pattern” is not always a Brugada ECG pattern

“…The differential diagnosis of an rSr′ pattern in leads V1 and V2 on the surface electrocardiogram (ECG) is a common issue in daily practice. This ECG pattern can be found in patients with prior cardiovascular disease, or in completely asymptomatic individuals as part of their routine medical exam 1 . The differential diagnoses should include Brugada syndrome, arrhythmogenic right ventricular dysplasia (ARVD), complete and incomplete right bundle branch block (RBBB), and normal variants in healthy individuals and athletes 2 …”

“…One of the very important messages from the work of Carrington et al 6 is that proper ECG interpretation may avoid unnecessary workup in these patients, and taking a proper history and conducting a physical examination may reduce the number of patients screened for underlying cardiac disease and potential Brugada syndrome 6 . In this sense, and before embarking on sophisticated ECG measurements, one could quickly run an algorithm to detect rSr′ patterns due to normal variations (incomplete RBBB), athletes, or the more common precordial lead displacement (inadvertent high‐precordial leads) 1,2 . Following this, using either the new tools suggested by Carrington et al 6 or the traditional β ‐angle and the base of the triangle, an initial analysis of the population to be screened could be performed based on a simple algorithm (Figure 1).…”

“…Note the necessary check (and correction if needed) of the precordial electrodes before starting the measurements. Modified from Reference [1]. ARVD, arrhythmogenic right ventricular dysplasia; CT, computed tomography; ECG, electrocardiogram; IRBBB, incomplete right bundle branch block; RV, right ventricle; V/Q, ventilation‐perfusion scan; WPW, Wolf–Parkinson–White syndrome.…”

“…6 In this sense, and before embarking on sophisticated ECG measurements, one could quickly run an algorithm to detect rSr′ patterns due to normal variations (incomplete RBBB), athletes, or the more common precordial lead displacement (inadvertent high-precordial leads). 1,2 Following this, using either the new tools suggested by Carrington et al 6 or the traditional β-angle and the base of the triangle, an initial analysis of the population to be screened could be performed based on a simple algorithm (Figure 1). After the initial screening with the use of a clinical algorithm, and the more sophisticated ECG analysis (in our algorithm we advocate for the "base of the triangle"), only those with confirmed Brugada ECG pattern (or ARVD) and/or a substantial degree of doubt should be referred to an arrhythmia specialist.…”

Methods for Improving the Diagnosis of a Brugada ECG Pattern

“…Although the type‐1 Brugada ECG pattern is diagnostic for BrS, the type‐2 Brugada ECG pattern requires differential diagnosis from conditions that produce a similar morphology . These include normal variant because of inadvertent placement of leads in the second and third intercostal space, incomplete right bundle branch block (IRBBB), healthy athletes, pectus excavatum, arrhythmogenic right ventricular dysplasia (ARVD), electrolyte abnormalities, and early repolarization . The ECG is an important tool in the evaluation of cardiac disease and although it appears to be relatively archaic, it continues to prove itself as a valuable instrument in the diagnosis of complex arrhythmic disease.…”