College Answer

a)
 Coved ST segment elevation V1 – V2 > 2 mm.
 Subsequent negative T wave in the same leads.
b)
 Brugada syndrome (Type 1).
c)
 A mutation in the cardiac sodium channel gene.
d)
 Fever.
 Myocardial ischaemia.
 Medications
o E.g. Flecainide, Amitriptyline, Lithium, Bupivacaine, Propofol, Alcohol.
 Hypokalaemia.
 Hypothermia.
 Cardioversion.

Discussion

The criteria for the diagnosis of Brugada syndrome as well as  are explored to a fascinating depth by Edward Burns in his article for LITFL. The time-poor exam candidate will be interested in only the answers to this question:

Clinical criteria:

• Characteristic ECG changes
  • "Coved" ST elevation:  the QRS complex finishes high, and the ST-segment slopes diagonally to form an inverted T-wave in V1 and V2
  • Inverted T waves
• Also, one of the following:
  • documented polymorphic VT or VF
  • Family history of sudden cardiac death before the age of 45
  • Characteristic ECG changes in family members
  • Syncope
  • Induceable VT
  • Nocturnal agonal respiration

Clinical situations which can worsen this condition:

• Ischameia
• Hyperthermia or hypothermia
• Hypokalemia
• Cardioversion
• Drugs:
  • Class 1 antiarrhythmics
  • Beta blockers and calcium channel blockers
  • Alpha-agonists
  • Nitrates
  • Cocaine and alcohol
  • Cholinergic agonists, eg. the "stigmine" drugs