New Electrocardiographic Criteria for Discriminating Between Brugada Types 2 and 3 Patterns and Incomplete Right Bundle Branch Block

Objectives The aim of this study was to evaluate new electrocardiographic (ECG) criteria for discriminating between incomplete right bundle branch block (RBBB) and the Brugada types 2 and 3 ECG patterns. Background Brugada syndrome can manifest as either type 2 or type 3 pattern. The latter should be distinguished from incomplete RBBB, present in 3% of the population. Methods Thirty-eight patients with either type 2 or type 3 Brugada pattern that were referred for an antiarrhythmic drug challenge (AAD) were included. Before AAD, 2 angles were measured from ECG leads V(1) and/or V(2) showing incomplete RBBB: 1) alpha, the angle between a vertical line and the downslope of the r'-wave, and 2) beta, the angle between the upslope of the S-wave and the downslope of the r'-wave. Baseline angle values, alone or combined with QRS duration, were compared between patients with negative and positive results on AAD. Receiver-operating characteristic curves were constructed to identify optimal discriminative cutoff values. Results The mean beta angle was significantly smaller in the 14 patients with negative results on AAD compared to the 24 patients with positive results on AAD (36 +/- 20 degrees vs. 62 +/- 20 degrees, p < 0.01). Its optimal cutoff value was 58, which yielded a positive predictive value of 73% and a negative predictive value of 87% for conversion to type 1 pattern on AAD; alpha was slightly less sensitive and specific compared with beta. When the angles were combined with QRS duration, it tended to improve discrimination. Conclusions In patients with suspected Brugada syndrome, simple ECG criteria can enable discrimination between incomplete RBBB and types 2 and 3 Brugada patterns. (J Am Coll Cardiol 2011; 58: 2290-8) (C) 2011 by the American College of Cardiology Foundation