What is the recommended treatment for Brugada syndrome?

Treatment Recommendations for Brugada Syndrome

For patients with Brugada syndrome, an implantable cardioverter-defibrillator (ICD) is the only treatment proven to reduce mortality in those with spontaneous type 1 Brugada ECG pattern who have experienced cardiac arrest, sustained ventricular arrhythmias, or recent syncope presumed due to ventricular arrhythmias. 1

Risk Stratification and Treatment Algorithm

High-Risk Patients (Class I recommendation)

• ICD implantation is indicated for:
  • Survivors of cardiac arrest
  • Patients with documented spontaneous sustained ventricular tachycardia (VT)
  • Patients with spontaneous type 1 Brugada ECG pattern AND recent history of syncope presumed due to ventricular arrhythmias

Intermediate-Risk Patients

• For patients with spontaneous type 1 Brugada ECG pattern and syncope:

  • ICD implantation should be considered (Class IIa) 1

• For asymptomatic patients with spontaneous type 1 Brugada ECG pattern:

  • Electrophysiological study (EPS) with programmed ventricular stimulation may be considered for risk stratification (Class IIb) 1
  • If ventricular fibrillation is inducible during EPS, ICD implantation may be considered 1

Low-Risk Patients

• For asymptomatic patients with only inducible type 1 Brugada ECG pattern:
  • Observation without therapy is recommended (Class I) 1

Alternative Therapies

For Patients Experiencing Recurrent ICD Shocks

• Quinidine or catheter ablation is recommended for:
  • Patients experiencing recurrent ICD shocks for polymorphic VT (Class I) 1
  • Treatment intensification with these options can reduce arrhythmic events

For Patients Who Cannot Receive an ICD

• Quinidine or catheter ablation is recommended for:
  • Patients with spontaneous type 1 Brugada ECG pattern and symptomatic ventricular arrhythmias who either:
    • Are not candidates for an ICD
    • Decline an ICD (Class I) 1

Diagnostic Considerations

• In patients with suspected Brugada syndrome without spontaneous type 1 ECG pattern, pharmacological challenge using sodium channel blockers (e.g., ajmaline, flecainide) can be useful for diagnosis (Class IIa) 1

Lifestyle Modifications

• All patients with Brugada syndrome should:
  • Avoid drugs that may induce ST-segment elevation in right precordial leads (www.brugadadrugs.org)
  • Avoid excessive alcohol intake and large meals
  • Promptly treat fever with antipyretic drugs 1

Genetic Testing

• Genetic counseling and testing may be useful to facilitate cascade screening of relatives (Class IIb) 1
• However, genetic testing results do not currently influence prognosis or treatment decisions 1

Complications and Considerations

• ICD therapy is associated with significant complications:

  • Inappropriate shocks (reported in 17-27% of patients) 2, 3, 4
  • Lead failures/dislodgments 2
  • Psychological impact (13.5% of patients in one study required psychiatric assistance) 2
  • Device infections 2

• Remote ICD monitoring should be considered as it can:

  • Decrease outpatient consultations
  • Help prevent inappropriate shocks through early detection of device issues 3

Key Pitfalls to Avoid

1. Overtreatment of asymptomatic patients: Studies show that appropriate ICD shocks are rare in asymptomatic patients without other risk factors 2, 5
2. Undertreatment of high-risk patients: Delaying ICD implantation in patients with syncope and spontaneous type 1 ECG pattern can lead to preventable sudden cardiac death
3. Failure to recognize triggers: Not addressing modifiable triggers like fever, certain medications, and alcohol can precipitate arrhythmic events
4. Inadequate follow-up: Patients with ICDs require regular monitoring to prevent complications and inappropriate shocks

Remember that Brugada syndrome has varying prevalence across populations, with higher rates in Southeast Asian populations (1 in 1,000 to 1 in 10,000) compared to Western populations 1.