Diagnosis of type 2 Brugada pattern: insights from a pilot survey

BACKGROUND: Differentiation of Type 2 Brugada Pattern (BP) from incomplete right bundle branch block or normal rSr’ pattern can be insidious. The aim of this study was to assess inter-observer and intra-observer agreement in the diagnosis of type 2 BP in a cohort of cardiologists with different skills.METHODS: We collected 14 ECGs with a positive terminal deflection of the QRS complex in lead V1 and V2 at the 4th intercostal space. We proposed these ECGs, specifying to use 2012 Consensus conference criteria for diagnosis of type 2 BP, to 42 participants: 14 arrhythmologists, 14 general cardiologists and 14 electrophysiology (EP) fellows. The same 14 ECGs, with a different order, were proposed fifteen days later to the same cohort to assess intra-observer variability. Authors analyzed all 14 ECGs in order to assess whether or not 2012 Consensus Conference criteria for BP were fulfilled. All patients underwent provocative test with IC antiarrhythmics drugs (flecainide) in order to exclude or confirm the diagnosis of Brugada Syndrome (BrS).RESULTS: Slight inter-observer agreement (Fleiss K<0.20) in the diagnosis of type 2 BP was observed in all three categories of cardiologists. Considering five operators per class, intra-observer agreement is variable (k ranging from 0,000 to 0,857), with a slight superiority of arrhytmologists (k minimum value 0,276; k maximum value 0,857).CONCLUSIONS: This study demonstrated, for the first time, a low inter-observer agreement in diagnosis of type 2 BP in categories of cardiologists with different abilities. Reproducibility of type 2 BP diagnosis (intra-observer agreement) is poor, even among experts. These findings highlight the difficulties in analysis of ECG with BrS suspicion and, therefore, underscore the key role of clinical and anamnestic data.