Spontaneous ST-Segment Elevation in Right Precordial Leads Following Cardiac Arrest: Literature Review and Management Proposal for Ruling out Brugada Syndrome

Purpose: Electrocardiogram (ECG) evaluation after return of spontaneous circulation (ROSC) represents a crucial step in the diagnostic work-up of sudden cardiac death (SCD) survivors. Among ECG patterns, the Brugada syndrome (BrS) type 1 morphology, characterized by coved ST-segment elevation in right precordial leads, requires a prompt differential diagnosis, as it may reflect either a true BrS, or a BrS phenocopy, or yet an acquired sodium channel dysfunction. Methods: This focused narrative review provides an analysis of Brugada-like ECG patterns occurring in the post-ROSC setting, summarizing the pathophysiological mechanisms, diagnostic criteria, and distinctive features of each potential etiology. Results: BrS is an inherited arrhythmogenic disorder associated with an increased risk of ventricular arrhythmias and SCD. Conversely, Brugada phenocopies are transient Brugada-like ECG patterns triggered by reversible conditions, including ischemia, pulmonary embolism, pneumothorax, hypothermia, electrolyte and metabolic disturbances, myocardial or pericardial inflammation, or intracranial hemorrhage. A diagnostic algorithm is proposed to guide clinicians through rapid evaluation, prioritizing the exclusion of life-threatening and reversible causes before considering primary electrical disorders. Conclusions: Early recognition and targeted management of these entities are fundamental, as prompt correction of the underlying condition often leads to complete ECG normalization, avoiding misdiagnosis. Understanding the spectrum of Brugada mimics is essential for improving diagnostic accuracy and optimizing therapeutic strategies in the acute management of post-cardiac arrest patients.