Vagally mediated ventricular arrhythmia in Brugada syndrome

Case report A 44-year-old man was admitted to the hospital after 2 episodes of syncope. Upon waking up at midnight, the patient proceeded to urinate, went back to his bed, and passed out. His wife noticed that he was not responding and started cardiopulmonary resuscitation. After about 2 minutes, the patient started to respond. An emergency medical services team was called, but before their arrival the patient experienced a shorter similar episode. When emergency medical services arrived he was alert, but felt fatigue. His blood pressure was normal. An electrocardiogram (ECG) at home showed slow atrial fibrillation (AF) with short–coupling interval premature ventricular contractions (280 ms) and ST elevation in V2-V3 and weak “covedtype” ST elevation in V1, compatible with Brugada syndrome (Figure 1). The AF converted spontaneously to sinus rhythm over the next few hours. The first ECG in sinus rhythm was recorded in the morning with right bundle branch block pattern and ST elevation compatible with Brugada syndrome, together with short-coupled ventricular premature beats (VPBs) (Figure 2). Later ECGs did not indicate a Brugada pattern. A 24-hour Holter monitor demonstrated sinus rhythm (average of 80 beats per minute [bpm]) and 320 VPBs with very short coupling intervals, less than 280 ms. An echocardiogram demonstrated normal left ventricular systolic function and normal structure and function of the heart chambers and valves. The exercise test was normal. Because