Hi Francesco, I would RV echo him, followed by cardiac MRI.

In such cases we perform 12 lead Holter-ECG as well.

I am not a medical doctor and can not answer this question

Hi

In case there is no abnormality in RV documented by MRI, just follow up every 2-3 years or before in case of symptoms.

Right bundle branch conduction delay may be a normal finding under IC drugs use (mimicking epsilon wave).

regards..

There are differences in opinion on how to manage this problem and it has led to some controversy within the cardiac community. However, no matter the controversy, there should be follow-up studies and risk stratification to determine the appropriate management strategy.  The Brugada article in Circulation (2005) has useful information and algorithms to help in identification and risk stratification of individuals suspected of having or are diagnosed with this condition.

Brugada, P, Brugada, R, & Brugada, J., 2005. Patients with an asymptomatic Brugada electrocardiogram should undergo pharmacological and electrophysiological testing. Circulation, 112, 279-292. Doi: 10.1161/CIRCULATIONAHA.104.485326

Conte, G, Sieira, J, Ciconte, G, de Asmundis, C., Baltogiannis, G., Di Giovanni, G.,La Meir, M.,...Brugada, P. 2015. Implantable cardioverter-defibrillator therapy in Brugada Syndrome: A 20-year single-center experience. J Am Coll Cardiol.65(9),879-888. doi:10.1016/j.jacc.2014.12.031

Whithout any ECG pattern of type 1 Brs this patient have not to be considered as affected by the syndrom.

However,you should performe Ajmaline test that could be more sensitive to unmask the pattern.

Whatever, in patient without spontaneous pattern or related symptoms, the risk remains low. A simple clinical follow up once a year (with ECG) could be of interest in this patient.

Here you find the

2013 HRS/EHRA/APHRS Expert Consensus Statement on the Diagnosis and Management of Patients with Inherited Primary Arrhythmia Syndromes

http://www.hrsonline.org/Practice-Guidance/Clinical-Guidelines-Documents/Management-of-Patients-with-Inherited-Primary-Arrhythmia-Syndromes#axzz3YUeEBXH6

In Short if the patient is not symptomatik (no syncope, no VT/VT) you should not implant an ICD but you should counsel him on

The following lifestyle changes are recommended in all patients with diagnosis o f BrS:

a)Avoidance of drugs that may induce or aggravate ST-segment elevation in right precordial leads (forexample, visit Brugadadrugs.org),

b) Avoidance of excessive alcohol intake.

c) Immediate treatment of fever with antipyretic drugs.

Are you sure you saw a epsilon wave? because that would more lead to ARVC, if so MRI for the right heart would be recommended, but still when the patient is not symptomatik you would not implant an ICD.

http://www.hrsonline.org/Practice-Guidance/Clinical-Guidelines-Documents/Management-of-Patients-with-Inherited-Primary-Arrhythmia-Syndromes#axzz3YUeEBXH6

I do not find of any usefulness to permorm a drug test in an asymptomatic healthy man!

An ECG is not a syndrome!

I normally would not refer an asymptomatic patient with a Type 2 Brugada pattern ("like" or phenocopy) for a drug challenge.  Are you comfortable with the lead positioning? Does the r' look narrow or wide? I am not sure what to make of a transient epsilon wave during flecainide challenge.  Did the QRS widen as well?  Maybe it was a drug effect.  If truly no symptoms, I would not work up for ARVC either.  Any way we can see the ECGs??

Dear prof. Martini

thanks for your kind reply. Patient was referred by a sport medicine doctor. 

We do agree that maybe a drug test could not be useful.

Aim of the question was to share this case  and to know if any other center expirienced this same feature during a drug test. Moreover recent literature is proving as an electrical delay conduction in RVOT can be found in pts with Brugada.

J Am Coll Cardiol. 2015 ;66(18):1976-86. 

J Am Coll Cardiol. 2016 ;67(12):1427-40.

see also this fascinating article:

Cardiac Electrophysiologic Substrate Underlying the ECG Phenotype and Electrogram Abnormalities in Brugada Syndrome PatientsJunjie Zhang, 

Frédéric Sacher, 

Kurt Hoffmayer, 

Thomas O'Hara, 

Maria Strom, 

Phillip Cuculich, 

Jennifer Silva, 

Daniel Cooper, 

Mitchell Faddis, 

Mélèze Hocini, 

Michel Haïssaguerre, 

Melvin Scheinman, 

and Yoram Rudy

Circulation. 2015;CIRCULATIONAHA.114.013698

published online before print March 25 2015, doi:10.1161/CIRCULATIONAHA.114.013698