INNOVATIVE COLLECTIONS RESEARCH ARTICLE Brugada Phenocopy with Epsilon-like Wave: Normal Variant? BARIS SENSOY, MD, OZCAN OZEKE, MD, MURAT GUL, MD, UGUR CANPOLAT, MD, SERKAN CAY, MD, SERKAN TOPALOGLU, MD and DURSUN ARAS, MD Turkiye Yuksek Ihtisas Training and Research Hospital, Department of Cardiology, Ankara, Turkey ABSTRACT. The primary objective of preparticipation screening is the detection of intrinsic structural or electrical cardiovascular disorders that predispose an athlete to sudden cardiac death. Both Brugada syndrome (BrS) and arrhythmogenic right ventricle cardiomyopathy (ARVC) can cause repolarization abnormalities in right precordial leads and predispose to sudden cardiac death due to ventricular arrhythmias. Although there is controversy over whether BrS is distinct from ARVC, it is believed that both are different clinical entities with respect to both the clinical presentation and the genetic predisposition. In clinical practice, there may be cases where the dividing line is not so clear, especially in asymptomatic patients or preparticipation individuals. We present a challenging electrocardiogram in a healthy person referred for preparticipation evaluation. KEYWORDS. Brugada phenocopy, electrocardiogram, epsilon wave, preparticipation screening. ISSN 2156-3977 (print) ISSN 2156-3993 (online) ’ 2015 Innovations in Cardiac Rhythm Management Introduction The appropriate screening strategy to prevent sudden cardiac death (SCD) in athletes remains a challenging and a highly debated issue. Both the 1996 American Heart Association (AHA) and the 2005 European Society of Cardiology (ESC) consensus panel recommendations agree that cardiovascular screening for young competitive athletes is justifiable and compelling on ethical, legal, and medical grounds. However, there is disagreement about the best approach. The AHA recommends history and physical examination; this approach is pragmatic and relatively inexpensive but has poor sensitivity because most athletes are asymptomatic and physical examination identifies only a minority of those at risk of sudden cardiac death. The inclusion of the electrocardiogram (ECG) in accordance with the recommendations of the ESC improves sensitivity for detection of serious cardiac disease but is associated with an unacceptably high false- positive rate, in part because of the overlap between the electrical manifestations of athletic training and the cardiomyopathies. For young athletes with normal ECG results, echocardiography contributes minimally to the diagnosis of serious cardiac diseases. 1 The primary objective of preparticipation screening is the detection of intrinsic structural or electrical cardio- vascular disorders that predispose an athlete to SCD. Arrhythmogenic disorders of genetic origin include structural cardiomyopathies and inherited arrhythmic syndromes. 2 Arrhythmogenic right ventricle cardiomyo- pathy (ARVC) is a myocardial disorder characterized by fibro-fatty replacement of the myocardium and ventri- cular arrhythmias. In contrast, Brugada syndrome (BrS) has long been considered a functional cardiac disorder: no gross structural abnormalities can be identified in the majority of patients. Although there is controversy over whether BrS is distinct from ARVC, it is believed that both are different clinical entities with respect to both the clinical presentation and the genetic predisposition. However, there is a subpopulation with a clinical and electrocardiographic pattern similar to that of BrS among patients with ARVC. The coexistence of these two relatively rare clinical entities is also reported, but some hypothesized that it is more possible that disease of the right ventricular muscle might accentuate the Brugada electrocardiographic pattern. In clinical practice there may be cases where the The authors report no conflicts of interest for the published content. Manuscript received December 10, 2014, final version accepted January 18, 2015. Address correspondence to: Ozcan Ozeke, MD, Tu ¨ rkiye Yu ¨ ksek I ˙ htisas Hastanesi, Kardiyoloji Klinigi, Ankara, 06100, Turkiye. E-mail: ozcanozeke@gmail.com The Journal of Innovations in Cardiac Rhythm Management, 6 (2015), 1920–1925 1920 The Journal of Innovations in Cardiac Rhythm Management, February 2015