Teaching Rounds in Cardiac Electrophysiology Does a Brugada Pattern ECG Precipitated by Excessive-Dose Flecainide Provide a Diagnosis of a Brugada Syndrome Patient and/or Contraindicate Its Use?

The patient is a 58-year-old white male cardiologist whofirst came to attention in 2004 at the age of 53 years, with a history of paroxysmal atrial fibrillation (PAF) dating to 1982. The episodes, which were often precipitated by recum-bency and alcohol, occurred 2 to 3 times per year and lasted only minutes. His ECG (Figure 1) while in normal sinus rhythm was normal. His PAF was not rapid and did not cause hemodynamic or ischemic symptoms. During 2003 to 2004, the PAF increased in frequency to several times per week and lasted longer, for which he began flecainide 50 mg bid with success for 6 months. Thereafter, however, they recurred with a progres-sive increase in frequency to several times per day, despite increasing the flecainide to 100 mg bid and then 150 mg bid and thereafter while trying sotalol up to 160 mg bid instead. A stress-echo was normal aside from a left atrial diamete