We read with great interest the article “Survival in Patients with Brugada Phenocopy. Case Series” by Fonseca et al. The authors describe a case series of patients with Brugada Phenocopy (BrP) and report in-hospital survival. We commend the authors for addressing an important topic related to BrP; however, we would like to comment on methodological considerations and propose recommendations that may strengthen interpretation and guide future BrP reports.

BrP refers to clinical conditions that lead to Brugada-ECG pattern (Br-ECGp) without the genetic substrate of Brugada Syndrome (BS) and an underlying condition that justifies the ECG change. The term was first used to describe the Br-ECGp caused by the propofol infusion syndrome; however, after several corrections to the concept, drugs that do block the sodium channels were no longer considered part of the BrP spectrum. BrP represents a diagnostic challenge even for experts. The mean accuracy to identify BrP based only on the 12-lead ECGs was 43±33% among 10 international experts. Therefore, the clinical context is essential to differentiate BrP from BS. Anselm et al. presented a systematic diagnostic criterion () for the diagnosis of BrP. Emphasis was placed on the recognition of the underlying clinical condition and the low pretest probability for BrP, in addition to the resolution of the Br-ECGp immediately after resolving the underlying condition. Based on the limited description provided by Fonseca et al., we cannot exclude the possibility that some cases represented concealed BS unmasked by hyperthermia or other triggers. This misclassification bias could alone skew the observed mortality.

[…]

Cardiopulmonary arrest (CRA) is the most serious event in the health area and its prompt recognition with the consequent initiation of cardiopulmonary resuscitation (CPR) maneuvers are essential for the return of spontaneous circulation (ROSC). Despite the absence of robust epidemiological data, a meta-analysis of 141 studies including countries in North America, Europe, Asia and Oceania, demonstrated a ROSC rate below 30% in cases of out-of-hospital CA, and concluded that the chances of success were linked to the fact that the CPR was witnessed and in cases where CPR had been initiated by a bystander.

In Brazil, according to the guideline on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of the Brazilian Society of Cardiology, the survival rates of out-of-hospital CPA, when addressed within the first 5 minutes with early defibrillation, vary between 50% and 70% two. On the other hand, in the in-hospital environment, paradoxically, survival rates are less than 20%, probably due to associated clinical conditions and the greater severity of patients, which make asystole and pulseless electrical activity the most prevalent rhythms.

[…]

Cardiovascular toxicity related to cancer therapies has been recognized for years. The number and types of toxicities have increased rapidly due to several factors including new and improved therapies and treatment regimens which have resulted in patients living longer. This is the basis for the burgeoning field of cardio-oncology to help identify cardiotoxicities and aim to minimize adverse outcomes.

Cardiomyopathies related to anthracyclines, which are typically irreversible, and trastuzumab, typically reversible, as well as more recently recognized cardiotoxicities including myocarditis related to immune checkpoint inhibitors have made the evaluation of concomitant cardiac disease critical in the care of patients being treated for cancer. ^, Coronary artery disease (CAD) is also a consequence of cancer therapies and adverse coronary events such as myocardial infarction and thrombosis can complicate treatment and result in poor outcomes. Thus, further understanding of the adverse effects of specific therapies is crucial to assessing patients’ clinical statuses and making decisions on treatment strategies in order to maximize overall outcomes, both oncologic and cardiac. CAD and has been associated with radiation therapy. ^, The risk and anatomic severity of CAD related to radiotherapy treatment has been described. ^, In a study of 152 thoracic cancer survivors who underwent radiotherapy, the investigators observed that the study patients had higher SYNTAX scores and were at a higher risk of developing anatomically severe CAD, independent of chemotherapy. While although CAD is known to be present in patients being treated with chemotherapy, independent of radiotherapy, the association between anatomic severity of CAD and chemotherapy is less well known.

[…]

Before the 80’s, the treatment of patients with ST–segment elevation myocardial infarction (STEMI) had as main goals the control of pain, arrhythmia and reduction of cardiac work, aiming to limit the extent of myocardial necrosis. These measures were partially effective, but the morbidity and mortality of acute myocardial infarction (AMI) remained high.

From the findings of Dewood, angiographically showing the presence of coronary occlusion by a thrombus in the culprit artery of the STEMI, strategies of reperfusion have emerged both thrombolytic therapy and primary percutaneous transluminal coronary angioplasty (PCI). The treatment of STEMI changes from contemplation to intervention.

[…]