Cite This Article

Zhou, R. Neegard, M. Denq, W. Dropping the Ball. Ortho Pearls. March 26, 2025; Available: https://www.orthoempearls.com/articles/dropping-the-ball

What is the most likely diagnosis?

This presentation and ECG is most consistent with Brugada Syndrome, a hereditary condition characterized by sodium-channel dysfunction which predisposes to ventricular tachyarrhythmias. 

The syndrome can be unmasked by medications, acute illness, drugs, or exercise, leading to syncope and/or cardiac arrest seen in our patient. ECG findings can be transient, but classically include a pseudo-right bundle branch block with persistent ST segment elevation in V1 and V2 [1], as seen in our patient’s ECG.

Image 2. ECG demonstrating pseudo-right bundle branch block with persistent ST segment elevation. Courtesy of Matthew Negaard.

• Pearl: Because the heart is structurally normal, auscultation usually will not reveal any extra heart sounds or murmurs. However, classic ECG findings, coupled with a family history of similar ECG findings or sudden cardiac death as well as personal history of syncope, documented ventricular fibrillation, or polymorphic ventricular tachycardia all support a diagnosis of Brugada [2,3]. 
• Pearl: In Brugada, Cardiac arrest most often results from ventricular fibrillation initiated by premature ventricular complexes [4]. Monomorphic ventricular tachycardia should prompt workup for other pathologies, such as arrhythmogenic cardiomyopathy.

Image 3. AED tracing before and after defibrillation. Case courtesy of Matthew Neegard.

What test should be emergently obtained to evaluate all athletes presenting after syncope?

All patients presenting to the Emergency Department after syncope should be evaluated with an ECG [5].

What cardiac diseases are more likely to cause cardiogenic syncope in young athletes?

In young athletes, the most common cause of sudden cardiac death (SCD) was previously thought to be hypertrophic cardiomyopathy [6]. Arrhythmogenic right ventricular cardiomyopathy is another common cause of SCD, whereas dilated cardiomyopathy is relatively uncommon. 

Recent studies have found that on post-mortem examination after SCD, the most common finding was autopsy negative sudden unexplained death– in other words, a structurally normal heart [7]. The presumed underlying cause of SCD in these cases is electrical disease and/or arrhythmia. Examples include Brugada Syndrome, Long QT and Short QT syndromes, and Wolff-Parkinson-White.

What can be done to screen for these diseases? What is the appropriate disposition and plan for RTP for this patient?

Pre-participation screening in asymptomatic patients involves assessment for abnormal exam findings (edema, S3, S4, murmurs, marfanoid habitus) and obtaining an ECG [6]. Screening can guide further testing, such as:

• Echocardiogram and/or cardiac MRI if structural disease is suspected.
• Holter monitor if electrical disease is suspected.
• Exercise stress testing for exertional symptoms.
• Genetic testing for patients with family history of sudden cardiac death. 

What is the appropriate disposition and plan for RTP for this patient?

Any patient presenting with exertional syncope and/or concern for Brugada syndrome should be hospitalized for further evaluation with continuous telemetry and cardiology consultation. The definitive treatment for Brugada is an implantable cardioverter-defibrillator [1,2]. 

Athletes should be restricted from sports participation until evaluation is completed. RTP for patients with Brugada syndrome can be considered after a period (e.g. 3 months) without symptoms [6]. At that point, shared decision-making will ultimately guide RTP. This process involves discussing risks, knowledge gaps, preferences with the athlete in conjunction with a cardiologist. It often requires multiple visits and a trusting physician-patient relationship for informed decisions.