Meera Ekka MD Praveen Aggarwal MD Department of Emergency Medicine All India Institute of Medical Sciences, Ansari Nagar New Delhi, India E-mail addresses: drmeera2004@yahoo.com peekay_124@hotmail.com http://dx.doi.org/10.1016/j.ajem.2013.10.013 References [1] Hossein-Nejad Hooman, Payandemehr Pooya, Bashiri Sayed Ali. Chest radiography after endotracheal tube placement: is it necessary or not? Am J Emerg Med 2013;31:1181–2. [2] Robert Maniscalco WM, Cohen AR, Litman RS, et al. The use of capnography for recognition of esophageal intubation in the neonatal intensive care unit. Pediatr Pulmonol 1995;19:262–8. [3] Sutherland PD, Quinn M. Nellcor; Stat Cap differentiates oesophageal from tracheal intubation. Arch Dis Child Fetal Neonatal Ed 1995;73:F184–6. [4] Phelan MP, Ornato JP, Peberdy MA, et al, American Heart Association's Get with the Guidelines-Resuscitation Investigators. 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Type 2 Brugada pattern is suggestive but not diagnostic of the syndrome To the Editor, We have read with great interest the article by Celik [1] et al in the American Journal of Emergency Medicine. The authors present a clinical case report involving a 23-year-old man attended in the emergency department 30 minutes after an episode of syncope. The initial electrocardiogram (ECG) showed rSr′ morphology in the precordial lead V1 and a saddleback pattern in V2, which the authors describe as Brugada type 2 ECG pattern. From this, they conclude that the patient had Brugada syndrome and make much of having obtained this early ECG since no further ECGs showed the patterns which characterize this syndrome [2]. However, this case report raises a number of issues which we would like to clarify: • The initial ECG presenting saddleback morphology is indeed suggestive of Brugada syndrome, but not sufficient. To establish the diagnosis, Brugada type 1 ECG pattern (Fig. 1) must be present, either manifesting spontaneously or after the adminis- tration of a sodium channel blocker [3]. • A recent consensus report on electrocardiographic criteria for types 1 and 2 Brugada pattern [4] describes new diagnostic tools to help differentiate them from other similar patterns. Applying these tools to the initial ECG presented by the authors, we measured the α and β angles first described by Chevallier et al [5] as well as the base of the triangle [4,6] as shown in Fig. 2. None of these measurements indicate that the patient had Brugada syndrome (Fig. 2). • V1-V2 electrodes are frequently placed on higher intercostal spaces than recommended, even in ECG recordings performed Fig. 1. Type 1 (A) and type 2 (B) Brugada electrocardiographic patterns. Only type 1 is diagnostic of Brugada syndrome. Type 2 requires sodium channel blocker administra- tion to reveal the pattern that confirms the diagnosis. by experts [7]. In these cases ECG patterns resembling the Brugada type 2 pattern can be obtained (Fig. 3), despite the absence of the syndrome. It would be interesting to see the ECG obtained 5 minutes after the initial recording, which the authors describe as normal, to evaluate whether the V1-V2 electrodes were placed differently. • It is very important to differentiate Brugada-like patterns from real Brugada patterns [8] because of the serious therapeutic and prognostic implications. Javier García-Niebla RN Jorge Díaz-Muñoz MD Servicios Sanitarios del Área de Salud de El Hierro Valle del Golfo Health Center Islas Canarias, Spain E-mail address: jniebla72@hotmail.com Miquel Fiol MD, PhD Hospital Universitario Son Espases Unidad Coronaria Palma de Mallorca, Spain http://dx.doi.org/10.1016/j.ajem.2013.10.014 References [1] Celik OF, et al. Earliest electrocardiogram is golden for the diagnosis of Brugada Syndrome. Am J Emerg Med 2013 [In press] http://dx.doi.org/10.1016/j.ajem.2013. 07.036. [2] Antzelevitch C, Brugada P, Borggrefe M, Brugada J, Brugada R, Corrado D, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation 2005;111:659–70. [3] Brugada R, Brugada J, Antzelevitch C, Kirsch GE, Potenza D, Towbin JA, et al. Sodium channel blockers identify risk for sudden death in patients with ST-segment elevation and right bundle branch block but structurally normal hearts. Circulation 2000;101:510–5. [4] Bayes de Luna A, Brugada J, Baranchuk A, et al. Current electrocardiographic criteria of diagnosis for types 1 and 2 Brugada pattern: a consensus report. J Electrocardiol 2012;45:433. [5] Chevallier S, Forclaz A, Tenkorang J, et al. New electrocardiographic criteria for discriminating between Brugada types 2 and 3 patterns and incomplete right bundle branch block. J Am Coll Cardiol 2011;58:2290. [6] Serra G, Goldwasser D, Capulzini L, et al. New ECG criteria taken from r′ characteristics for differentiate type 2 Brugada pattern from incomplete RBBB in athletes. Abstract accepted to European Congress of Cardiology; 2012. [7] Wenger W, Kligfield P. Variability of precordial electrode placement during routine electrocardiography. J Electrocardiol 1996;29:179–84. [8] Baranchuk A, Nguyen T, Ryu MH, et al. Brugada phenocopy: new terminology and proposed classification. Ann Noninvasive Electrocardiol 2012;17:299–314. 97 Correspondence / American Journal of Emergency Medicine 32 (2014) 86–106