Saturday, April 25, 2015

Syncope and a Possible Type 2 Brugada Morphology

A young man had 10 seconds of syncope without a prodrome.  He had had it once before.  Exam was normal.

This ECG was recorded:
There is rSr' in both V1 and V2, with a "saddleback" in lead V2, and the "beta" angle is wide.  It meets, or at least nearly meets, criteria for type 2 Brugada.

Having just written on this topic, I knew that this could be the result of lead placement that is too high.

V1 and V2 should be placed at the 4th intercostal space.  Placing them at the 3rd can result in false positives for Brugada.

I asked the tech if she was sure she had placed them correctly.

She returned saying that she had placed them one interspace too high, and handed me this ECG recorded at the right interspace:

The rSr' is gone and the saddle is gone as well.

Learning point:

Beware lead placement in the diagnosis of right ventricular conduction delay (rSr") and in the finding of Brugada pattern ECG.


  1. Steve thanks for clarifying the lead placement pearl, but in your book it states to place V1-2 in the 3rd intercostal space. Is this something we need to remember to change in our book?

    1. That is a mistake in my book! Sorry about that.

  2. I thought detection of these changes was improved by placing the leads 1-2 spaces higher.

    1. Andrew,
      Now I will admit that is confusing! This is the way I understand it: Recording too high can be a false positive for Brugada. However, if there is a potential Brugada on an ECG with well placed leads, it must also show up on higher leads; if it does not, that is good evidence against Brugada. It may be important in cases of high suspicion for transient or concealed Brugada syndrome to detect Brugada when it does NOT show in the 4th intercostal space.
      Read this article:
      And this article:

    2. Dr. Smith you said he had syncope once before.. was an etiology suspected or identified?

  3. Hi! Sorry because Im not cardiologist but neurologist. I have a question: why does it appear that rSr pattern in v1 in some people only when you put that lead high? Is it common? If i saw that i would think of brugada! Thanks!

    1. Aiora,
      Lead position always affects the morphology. If late activation is directed superior, then a more superior lead will better detect that late activation and show an r'-wave. OK?
      Steve Smith


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