**4. The Breijo pattern**

As we have mentioned earlier, the first case of **Breijo pattern** was published in the International Journal of Cardiology in 2008.

The patient was a 37-year-old male, born in Mexico, D.F.

Since his childhood, he had suffered from tonic–clonic seizures and was treated with antiepileptic drugs (concretely with valproic acid) but without any epileptogenic focus showing up on his electroencephalogram.

Since then, the patient referred multiple accesses of nocturnal palpitations, accompanied by intense sweating that wet the pajamas. Feelings of gait instability. He liked to play sports, but at the minimum effort, he felt severe palpitations that impeded him from continuing with it.

The patient was anxious about his heart and visited numerous specialists in the field. He underwent a lot of diagnostic tests, and all of them were considered normal. The doctors believed him to be a patient with intense anxiety and hypochondriasis.

In two occasions, the patient suffered two syncope events that were considered vase-vagal etiology.

A thorough compilation of patients with this kind of symptoms such as infantile convulsions non-responders to conventional treatments, bouts of nocturnal tachycardia with sudden character, and syncopal events related to the effort.

An exhaustive study of personal antecedents, as well as your current clinical situation, was performed.

An exhaustive measurement of intervals, segments, and electrocardiographic waves. Measurement technique: MioLaserTool®, Pixruler® & Cardiocaliper®.

By way of example, we will expose the following case: A 37-year-old man with much nocturnal tachycardia crisis (since childhood) and three syncopal events observed and related to physical stress. In his family background, two sudden deaths were found: father died at age 55 of sudden cardiac, and a brother died at 22 months by sudden infant death.

He was diagnosed in his Reference Hospital (where he was transferred by emergency services) with supraventricular tachycardia to 195–200 beats/min (**Figure 3**), with narrow QRS

**Figure 3.** The full basal electrocardiogram tracing.

Of all the current layouts, this is the one we consider as the most reliable and the most accurate. We have seen cases of a short QT interval (QTc ≤ 0.350 s) in asymptomatic patients and with-

We also think it is worthy to mention an interesting paradoxical ECG phenomenon called deceleration-dependent shortening of QT interval (shortening of QT interval associated with a decrease in heart rate); this should also be considered in a differential diagnosis

In order to know precisely if the corrected QT value—by the different existing formulas—is in

As we have mentioned earlier, the first case of **Breijo pattern** was published in the International

Since his childhood, he had suffered from tonic–clonic seizures and was treated with antiepileptic drugs (concretely with valproic acid) but without any epileptogenic focus showing up

out a positive family history thereto for congenital (and non-genetic) character.

ranges, we use the **Boston diagram** (**Figure 2**).

The patient was a 37-year-old male, born in Mexico, D.F.

**4. The Breijo pattern**

**Figure 2.** Boston Diagram.

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Journal of Cardiology in 2008.

on his electroencephalogram.

[1–3].

complexes. Severe diaphoresis, with the paleness of skin and mucous. A severe arterial hypotension to 90/50 mm Hg. Cardiac auscultation was in normal ranges but with a rapid rhythm. Tachypnea to 20 cycles/min. A grade Stuporous (Glasgow 15/15). The neurological examination was within normal ranges without focalizations. Central and peripheral pulses were palpable, symmetric, and synchronous in "frecuens". Supraventricular tachycardia disappeared using the administration of two doses of Adenosine i.v. in bolus, with six mgrs. Each one in 1 min (**Figure 4**). A hospital discharge was made after full stabilizing of acute process and patient was derived from your cardiologist outpatient, with the following diagnosis. A paroxysmal supraventricular tachycardia and Crisis of anxiety. The patient was transferred to our hospital because he had a similar event as the exposed, after the first visit with his outpatient cardiologist. There, the patient was adequately assessed with electrocardiogram, echocardiogram, blood levels of ions, and cardiac markers as well as electrophysiological study (EEF) (**Figure 5**). He was negative for high levels of Troponin (I-T), CK, CPK-MB; however, he was positive for low levels of lithium-ion (<0.1 mEq/L).

Nevertheless, in an in-depth and careful study of his basal electrocardiogram, we were able to assess the existence of a short PR and QTc interval.

Below, we present the first electrocardiogram of the patient that we were able to assess.

(Despite the fact that we practice a full series of tests on the patient, the most significant in this exposure is the electrocardiography and the Holter studies).

In 60 bpm can be seen the short PR-interval (< 0.120 s) together in the short QT-interval

**Figure 5.** Same features as in **Figure 1**. PQ-interval: 0.100–0.110 s = Short PQ-interval. QTc (Bazzet) 0.339–0.340 s (<

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A differential diagnosis is imperative for any electrocardiographic entity that has a shortened

**Entity PR-interval QRS complex QTc-interval** WPW Short Wide (δ-wave) Normal L.G.L Short Normal Normal Breijo pattern Short Normal Short Mahaim Normal or short Normal or wide Normal

(< 0.350 s.). Chiefly in inferior and precordial leads. On the Boston Diagram, it would be (red marked).

0.350 s) = Short QT-interval. QTc (Fridericia) 0.332 s (< 0.350 s) = Short QT-interval.

**5. Differential diagnosis**

These are fundamentally.

**1.** Wolff-Parkinson-White **(W P W).**

**2.** Lown-Ganong-Levine **(LGL).**

PR interval.

**3.** Mahaim.

**Figure 4.** Graphic representation of the value obtained on the Boston diagram.

**Figure 5.** Same features as in **Figure 1**. PQ-interval: 0.100–0.110 s = Short PQ-interval. QTc (Bazzet) 0.339–0.340 s (< 0.350 s) = Short QT-interval. QTc (Fridericia) 0.332 s (< 0.350 s) = Short QT-interval.

In 60 bpm can be seen the short PR-interval (< 0.120 s) together in the short QT-interval (< 0.350 s.). Chiefly in inferior and precordial leads.

On the Boston Diagram, it would be (red marked).

## **5. Differential diagnosis**

A differential diagnosis is imperative for any electrocardiographic entity that has a shortened PR interval.

These are fundamentally.


complexes. Severe diaphoresis, with the paleness of skin and mucous. A severe arterial hypotension to 90/50 mm Hg. Cardiac auscultation was in normal ranges but with a rapid rhythm. Tachypnea to 20 cycles/min. A grade Stuporous (Glasgow 15/15). The neurological examination was within normal ranges without focalizations. Central and peripheral pulses were palpable, symmetric, and synchronous in "frecuens". Supraventricular tachycardia disappeared using the administration of two doses of Adenosine i.v. in bolus, with six mgrs. Each one in 1 min (**Figure 4**). A hospital discharge was made after full stabilizing of acute process and patient was derived from your cardiologist outpatient, with the following diagnosis. A paroxysmal supraventricular tachycardia and Crisis of anxiety. The patient was transferred to our hospital because he had a similar event as the exposed, after the first visit with his outpatient cardiologist. There, the patient was adequately assessed with electrocardiogram, echocardiogram, blood levels of ions, and cardiac markers as well as electrophysiological study (EEF) (**Figure 5**). He was negative for high levels of Troponin (I-T), CK, CPK-MB; however, he was positive for

Nevertheless, in an in-depth and careful study of his basal electrocardiogram, we were able to

(Despite the fact that we practice a full series of tests on the patient, the most significant in this

Below, we present the first electrocardiogram of the patient that we were able to assess.

low levels of lithium-ion (<0.1 mEq/L).

152 Cardiac Arrhythmias

assess the existence of a short PR and QTc interval.

exposure is the electrocardiography and the Holter studies).

**Figure 4.** Graphic representation of the value obtained on the Boston diagram.


Differential diagnosis, based on the characteristics of the different intervals and complex.

*Disease"* as can be seen in **Figure 6**.

trocardiographic **Breijo pattern,** as can be seen in **Figure 8**.

**Figure 8.** A *WPW* alongside a **Breijo pattern** can be perfectly seen in the image [14, 15].

**Table 2.** Assessment of the values obtained according to the different formulas used.

**Figure 7** [12, 13].

This **"Breijo pattern"** we have assessed both in isolation and in association with other kinds of cardiac pathologies such as *"Wellens Pattern", Wolf-Parkinson-White* syndrome and in "*Takotsubo's* 

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The *"Broken heart syndrome"* (**Takotsubo**) and the **Breijo pattern** are correctly appreciated in

We have also known the existence of a *Wolf-Parkinson-White syndrome* associated with an elec-

**Figure 6.** A **Breijo pattern** along with a *Wellens Pattern* can be valued in the image [10, 11].

**Figure 7.** Electrocardiographic and arteriographic imaging of Takotsubo syndrome.

Differential diagnosis, based on the characteristics of the different intervals and complex.

This **"Breijo pattern"** we have assessed both in isolation and in association with other kinds of cardiac pathologies such as *"Wellens Pattern", Wolf-Parkinson-White* syndrome and in "*Takotsubo's Disease"* as can be seen in **Figure 6**.

The *"Broken heart syndrome"* (**Takotsubo**) and the **Breijo pattern** are correctly appreciated in **Figure 7** [12, 13].

We have also known the existence of a *Wolf-Parkinson-White syndrome* associated with an electrocardiographic **Breijo pattern,** as can be seen in **Figure 8**.

**Figure 8.** A *WPW* alongside a **Breijo pattern** can be perfectly seen in the image [14, 15].


**Table 2.** Assessment of the values obtained according to the different formulas used.

**Figure 7.** Electrocardiographic and arteriographic imaging of Takotsubo syndrome.

**Figure 6.** A **Breijo pattern** along with a *Wellens Pattern* can be valued in the image [10, 11].

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**6. Some significant images typical of the Breijo pattern**

**Figure 9.** A full electrocardiogram performed with a Breijo pattern, in a male person.

A typical image of a Breijo pattern in precordial left leads (**Table 2**).

nately died due to not being able to be recovered from a sudden death.

In a nutshell, we can say the following about Breijo pattern as conclusions:

Measured QTc value: Between 0.356 and 0.334 s very short).

The last electrocardiogram performed with a **Breijo pattern**, in a male person who unfortu-

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The electrocardiographic tracing was considered as within acceptable limits and his doctors

**1.** Although relatively little known so far, it is increasingly being discovered in ECG tracings

Measured PR interval: 0.988 s.

In the Boston diagram at 68 bpm.

decided to send him home (**Figure 9**). PR interval value: 0.89 s (Very short).

that at first glance may appear normal.

Calculated QTc interval:

\*\* Square in red.

**Figure 9.** A full electrocardiogram performed with a Breijo pattern, in a male person.
