What is the management approach for a patient presenting with a Brugada pattern on their electrocardiogram (ECG)?

From the Guidelines

Management of a patient with a Brugada pattern on ECG requires careful risk stratification and specialized cardiac care, with implantable cardioverter-defibrillator (ICD) placement being the only proven therapy to prevent sudden cardiac death in symptomatic patients. Patients with symptomatic Brugada syndrome (those with syncope, seizures, or cardiac arrest) should be referred urgently to a cardiac electrophysiologist for ICD placement, as recommended by the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1. For asymptomatic patients with incidental Brugada pattern findings, risk stratification is essential through comprehensive cardiac evaluation including electrophysiology studies.

Key Considerations

• All patients should avoid triggering factors such as certain medications (Class I antiarrhythmics, tricyclic antidepressants, and some anesthetics), excessive alcohol intake, and fever, as these can unmask or exacerbate the Brugada pattern 1.
• Fever should be promptly treated with antipyretics, as it can trigger or worsen the Brugada pattern 1.
• Quinidine (300-600 mg twice daily) may be used as adjunctive therapy in patients who cannot receive an ICD or have frequent ICD shocks, as suggested by the 2017 AHA/ACC/HRS guideline 1.
• Genetic counseling is recommended for patients and family members, as Brugada syndrome has an autosomal dominant inheritance pattern with SCN5A mutations present in approximately 20-30% of cases 1.

Additional Recommendations

• In patients with suspected Brugada syndrome in the absence of a spontaneous type 1 Brugada electrocardiographic pattern, a pharmacological challenge using a sodium channel blocker can be useful for diagnosis, as recommended by the 2017 AHA/ACC/HRS guideline 1.
• In patients with asymptomatic Brugada syndrome and a spontaneous type 1 Brugada electrocardiographic pattern, an electrophysiological study with programmed ventricular stimulation using single and double extrastimuli may be considered for further risk stratification, as suggested by the 2017 AHA/ACC/HRS guideline 1.
• Catheter ablation may be considered in patients with a history of electrical storms or repeated appropriate ICD shocks, as recommended by the 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1.

From the Research

Management Approach for Brugada Pattern

The management approach for a patient presenting with a Brugada pattern on their electrocardiogram (ECG) involves several key considerations:

• Implantable Cardioverter-Defibrillator (ICD): The guidelines recommend the implantation of an ICD for the prevention of sudden cardiac death (SCD) in patients with Brugada syndrome 2, 3.
• Pharmacological Therapy: Quinidine has been shown to be effective in preventing ventricular arrhythmias (VA) in patients with Brugada syndrome, although it is burdened by a high incidence of side effects 3, 4, 5.
• Genetic Testing: Genetic testing, such as next-generation sequencing (NGS), can help identify pathogenic variants in the SCN5A gene, which is associated with autosomal dominant Brugada syndrome 2.
• ECG Monitoring: ECG monitoring with modified precordial lead positioning can help confirm the presence of the Brugada phenotype and diagnose the condition 2.

Treatment Options

Treatment options for patients with Brugada syndrome include:

• ICD Implantation: ICD implantation is the primary treatment for preventing SCD in patients with Brugada syndrome 2, 3.
• Quinidine Therapy: Quinidine therapy can be used to prevent VA in patients with Brugada syndrome, although it is not without side effects 3, 4, 5.
• Lifestyle Modifications: Patients with Brugada syndrome should avoid certain medications and activities that can trigger VA, such as fever and dehydration 6.

Diagnosis and Risk Stratification

Diagnosis and risk stratification of Brugada syndrome involve:

• ECG Interpretation: ECG interpretation is crucial for diagnosing Brugada syndrome, and modified precordial lead positioning can help confirm the presence of the Brugada phenotype 2.
• Genetic Testing: Genetic testing can help identify pathogenic variants in the SCN5A gene and diagnose autosomal dominant Brugada syndrome 2.
• Family History: A family history of sudden cardiac death or Brugada syndrome can increase the risk of developing the condition 2.