What is the management for a patient with a Brugada (Electrocardiogram) EKG pattern?

Management of Patients with Brugada EKG Pattern

The management of patients with Brugada EKG pattern should be based on risk stratification, with implantable cardioverter defibrillator (ICD) implantation recommended for high-risk patients who have experienced cardiac arrest, documented ventricular tachycardia, or syncope with spontaneous type 1 Brugada pattern. 1

Risk Stratification

Risk stratification is essential for determining appropriate management:

High-Risk Patients (Class I recommendation for ICD)

• Survivors of aborted cardiac arrest
• Patients with documented spontaneous sustained ventricular tachycardia (VT)
• Patients with spontaneous type 1 Brugada ECG pattern and history of syncope

Intermediate-Risk Patients (Class IIb recommendation for ICD)

• Asymptomatic patients with spontaneous type 1 Brugada ECG pattern
• Patients who develop ventricular fibrillation (VF) during programmed ventricular stimulation with two or three extrastimuli

Low-Risk Patients (Observation recommended)

• Asymptomatic patients with only inducible (drug-induced) type 1 Brugada ECG pattern

Management Algorithm

1. For High-Risk Patients:

• ICD implantation is the only proven therapy to reduce risk of sudden cardiac death 1
• Consider quinidine or catheter ablation for patients experiencing recurrent ICD shocks for polymorphic VT 1
• For patients who are not candidates for or decline an ICD, quinidine or catheter ablation is recommended 1

2. For Electrical Storm:

• Isoproterenol should be considered as first-line treatment 1
• Quinidine should be considered as an alternative 1

3. For All Patients with Brugada Syndrome:

• Implement lifestyle modifications:
  • Avoid drugs that may induce ST-segment elevation in right precordial leads (consult www.brugadadrugs.org) 1
  • Avoid excessive alcohol intake and large meals 1
  • Prompt treatment of any fever with antipyretic drugs 1
  • Avoid triggers such as cocaine and other recreational drugs 1, 2

4. For Diagnostic Evaluation:

• In patients with suspected Brugada syndrome without spontaneous type 1 pattern, pharmacological challenge using sodium channel blockers (flecainide, procainamide, ajmaline) can be useful 1
• High electrode positioning (2nd and 3rd intercostal spaces) improves detection of type 1 Brugada ECG 1

Special Considerations

Genetic Testing

• Genetic testing may be considered to facilitate cascade screening of relatives 1
• However, genetic testing results do not currently influence prognosis or treatment 1
• SCN5A variants account for most genotype-positive cases, but only 20-30% of phenotype-positive patients have identifiable genetic mutations 1

Electrophysiological Study (EPS)

• The prognostic value of programmed ventricular stimulation is debated 1
• May be considered for further risk stratification in asymptomatic patients with spontaneous type 1 Brugada ECG pattern 1

Catheter Ablation

• May be considered in patients with history of electrical storms or repeated appropriate ICD shocks 1
• Epicardial ablation over the anterior right ventricular outflow tract has shown promise in preventing electrical storms 1

Pitfalls and Caveats

1. Medication-induced Brugada pattern: Some medications can unmask or induce Brugada pattern, including antiarrhythmics, psychotropics, and anticonvulsants like phenytoin 3, 4. This does not necessarily indicate true Brugada syndrome.

2. Fever management: Fever can unmask Brugada pattern and trigger arrhythmias, making aggressive antipyretic treatment crucial 1.

3. Risk assessment limitations: While we have reasonable ability to predict ICD-recorded fast ventricular arrhythmias, our ability to predict sudden death in patients without ICDs is limited 5.

4. Asymptomatic patients: Management of asymptomatic patients with spontaneous type 1 pattern remains controversial, with conflicting data regarding their risk 6.

5. Quinidine availability: Despite its usefulness, quinidine may have limited availability in some regions and can cause adverse effects in up to 38% of patients 1.