Are beta blockers (beta-adrenergic blocking agents) recommended for patients with Brugada syndrome?

Beta Blockers in Brugada Syndrome

Beta blockers are not recommended for patients with Brugada syndrome and may potentially be harmful by unmasking or exacerbating the ECG pattern and precipitating life-threatening ventricular arrhythmias. 1

Rationale and Evidence

The 2017 AHA/ACC/HRS guidelines for management of patients with ventricular arrhythmias and prevention of sudden cardiac death provide specific recommendations for Brugada syndrome management, but notably do not include beta blockers as a recommended therapy 2. Instead, the guidelines emphasize:

• Observation without therapy for asymptomatic patients with only inducible type 1 Brugada ECG pattern
• ICD implantation for symptomatic patients with spontaneous type 1 Brugada ECG pattern
• Quinidine or catheter ablation for patients experiencing recurrent ICD shocks or those who are not candidates for ICD

Contraindications and Risks

Beta blockers are specifically identified as potentially harmful in Brugada syndrome for several reasons:

• They can unmask or exacerbate the characteristic Brugada ECG pattern (ST-segment elevation in right precordial leads) 1
• They may increase the risk of ventricular arrhythmias by altering autonomic balance 3
• They are listed among medications that should be avoided according to expert consensus 1, 4

The European Society of Cardiology (ESC) guidelines explicitly state that avoidance of drugs that may induce ST-segment elevation in right precordial leads is a Class I recommendation for all patients with Brugada syndrome, with beta blockers specifically mentioned among contraindicated medications 1.

Medication Management in Brugada Syndrome

Medications to Avoid

• Beta blockers
• Class I antiarrhythmic drugs (sodium channel blockers)
• Certain calcium channel blockers
• Tricyclic antidepressants
• Other medications listed on www.brugadadrugs.org 1, 4

Recommended Management Approaches

1. ICD implantation: Gold standard therapy for high-risk patients with Brugada syndrome 2, 1
2. Quinidine: May be considered for patients with recurrent ICD shocks or for treatment of supraventricular arrhythmias 2, 1
3. Isoproterenol: Can be used to treat electrical storms in Brugada syndrome 1, 5

Clinical Considerations and Pitfalls

Important Triggers to Avoid

• Fever (requires prompt treatment with antipyretics) 1
• Excessive alcohol intake 1
• Large meals 1
• Certain medications (check www.brugadadrugs.org before prescribing) 1, 4

Common Pitfalls

1. Medication errors: A Danish nationwide cohort study found that one in three patients with Brugada syndrome were prescribed contraindicated medications after diagnosis, highlighting the need for increased awareness 4

2. Misdiagnosis of ECG changes: The ECG manifestations of Brugada syndrome are often dynamic or concealed and may be unmasked by various factors including beta-adrenergic blockers 3

3. Confusing with other channelopathies: While beta blockers are beneficial in other channelopathies like Long QT syndrome and Catecholaminergic Polymorphic Ventricular Tachycardia (explicitly recommended in guidelines 2), they are potentially harmful in Brugada syndrome 5

Patient Education

All patients with Brugada syndrome should be:

• Directed to www.brugadadrugs.org to check medication safety before taking any new drugs 1
• Educated about avoiding triggers like excessive alcohol intake and promptly treating fever 1
• Informed about the importance of avoiding beta blockers and other contraindicated medications 1, 4

By following these evidence-based recommendations and avoiding beta blockers, clinicians can help reduce the risk of life-threatening arrhythmias and sudden cardiac death in patients with Brugada syndrome.