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Brugada Phenocopy: Morphological Classification and Importance of Provocative Testing

Dear Editor, We read the excellent case report by Rambod et al.1 regarding Brugada phenocopy (BrP) in the context of concomitant heroin and ethanol overdose with great interest. This case is important as it contributes to the growing body of literature describing BrP;2–6 however, there are salient points that require further discussion and investigation. We have recently developed a morphological classification system which divides BrP into a type 1 and type 2 BrP according to the manifested ECG pattern. The type 1 BrP is identical to a coved or type1 Brugada ECG pattern and the type 2 BrP is identical to a saddleback or type 2 Brugada ECG pattern.3,5,6 These two categories include A, B, and C qualifiers (Table 1). Class A includes BrP that have met all mandatory diagnostic criteria including negative provocative challenge with a sodium channel blocker. Class B includes highly suspected BrP; however, not all mandatory diagnostic criteria are complete. These are cases where mandatory provocative challenge is not possible due to various factors such as the patient being deceased or lost to follow-up. Class C includes highly suspected BrP; however, provocative testing is not justified such as in cases with recent surgical right ventricular outflow tract manipulation7 or BrP secondary to inappropriate ECG high pass filters.8