When an ECG Reveals a Secret, and the Patient Disappears

I picked up my next patient for the day – a young 31-year-old guy, presenting with a bit of a cough and chest pain, a few days after testing positive for Flu A. Vitals were rock solid, temperature was normal – nothing too alarming on the surface. No significant medical history to speak of in his records. Pretty standard stuff, right?

Then I glanced at his ECG. And my jaw pretty much hit the floor

This is a classic, Type 1 Brugada pattern. See that coved ST-segment elevation in V1 and V2, followed by a negative T wave? That's the characteristic "shark fin" appearance that screams Brugada.

And in his case, it was spontaneous – not provoked by any drugs or fever at the time of the ECG.

Now, as you can imagine, seeing something like this in an otherwise well, young patient immediately sets off alarm bells. Brugada Syndrome is an inherited channelopathy that can lead to life-threatening arrhythmias, even sudden cardiac death.

The problem? My patient, after having his ECG done, decided he'd had enough of the ED and absconded!

So, here I am, with a potentially critical incidental finding on an ECG, and no patient to talk to! What do you do?!

We treat these incidental spontaneous Type 1 Brugada patterns according to established guidelines, like the ESC algorithm you can see here:

This flowchart helps us navigate the next steps, especially when we can't get the full story from the patient.

Even though he wasn't there, my mind immediately ran through the key questions we would have asked to assess his risk and determine the urgency of follow-up:

The Essential Questions

* Symptoms:

* "Have you ever fainted (syncope), especially at rest?"

* "Have you had episodes of palpitations, seizures, or near-collapse?"

* "Have you ever had sudden waking from sleep with gasping or a racing heart?

* Family History:

* "Has anyone in your family died suddenly under the age of 45?"

* "Any unexplained drownings, car accidents, or SADS (Sudden Arrhythmic Death Syndrome)?

* Drug/Temperature Triggers:

* "Any symptoms after taking medications, especially during fever?

* "Are you on any new medications?" (Always cross-check at brugadadrugs.org – it's an invaluable resource for meds that can exacerbate Brugada!).

Immediate ED Action

Given that he was asymptomatic at the time of the ECG and we had no family history (because he absconded!), this would ideally fall under the "Asymptomatic incidental finding" pathway. In a perfect world, we would:

* Document: Every single detail. This ECG, the finding, the patient's presentation, and the fact he absconded.

* Reassure: If he was still there, we'd reassure him calmly, explain the finding, and the need for follow-up.

* Refer non-urgently to Cardiology