Utility of Different Electrocardiographical Leads during Diagnostic Ajmaline Test for Suspected Brugada Syndrome

In order to compare the value of different leads and lead combinations to detect the signature Brugada type ECG pattern, we analysed digital 10-second, 15-lead ECGs (12 standard leads + leads V1 to V3 from 3rd intercostal (i.c.) space, V1h to V3h) acquired during diagnostic Ajmaline testing in 128 patients (80 men, age 37±15 years) with suspected Brugada syndrome (BS) (patient group), 15-lead resting ECGs of 108 healthy subjects (53 men, age 31.9±10.5 years) (control group A) and standard 12-lead resting ECGs of 229 healthy subjects (111 men, age 33±4 years) (control group B). Bipolar leads between V2 (positive pole) and V4 or V5 (leads V2-4V2-5) were derived by subtracting leads V4 and V5 from V2 (custom-made program). The 6 peripheral, 6 right precordial leads (V1 to V3, V1h to V3h) and leads V2-4 and V2-5 of the patients group, leads V1h to V3h of control group A, and leads V2-4 and V2-5 of control group B were analysed for the presence of type 1 Brugada pattern. There were 21 (16.4%) positive and 107 (83.6%) negative Ajmaline tests. In 7 positive tests (33%), type 1 pattern appeared only in leads V1h to V3h, whereas in 14 tests 67%) it appeared in both V1 to V3 and V1h to V3h. Lead V2 displayed type 1 pattern during 10 positive tests; in all of them, plus 10 other positive tests type 1 was also noted in lead V2h (n=20, 95.2%). In all 10 cases, in which lead V2 exhibited type 1 pattern (n=10), lead V2-4 and/or V2-5 also exhibited type 1-like pattern. During 7 positive tests, in which lead V2h but not V2 exhibited type 1 pattern, lead V2-4 and/or V2-5 also demonstrated type 1 pattern. Type 1 pattern was observed in leads V3 and V3h during 1 (5%) and 5 (24%) positive tests, in 0 ECGs (0%) in control group A and in 1 ECG (0.4%) in control group B. In conclusion, the "high" V1 and V2 leads (3rd i.c. space) detect more sensitively Brugada type 1 pattern than the standard V1 and V2 leads (4th i.c. space); leads V3 and V3h are not essential for the diagnosis of BS; bipolar leads V2-4 and V2-5 are superior to lead V2 for the ECG diagnosis of BS.