Is Propafenone (anti-arrhythmic medication) safe for patients with Brugada syndrome?

Propafenone is Contraindicated in Patients with Brugada Syndrome

Propafenone is absolutely contraindicated in patients with Brugada syndrome and should never be used in these patients due to the significant risk of life-threatening arrhythmias. 1

Mechanism and Risks

• Propafenone is a Class IC antiarrhythmic drug that can unmask or exacerbate the Brugada ECG pattern by blocking sodium channels, potentially triggering ventricular arrhythmias in susceptible individuals 1, 2
• Propafenone can induce Brugada phenocopy (Brugada-like ECG pattern) even in patients without the genetic syndrome, highlighting its potent sodium channel blocking effects 2
• Case reports document propafenone overdose causing Brugada-pattern ECG changes and potentially life-threatening arrhythmias 2

Guidelines and Contraindications

• The 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia explicitly lists Brugada syndrome as a contraindication for propafenone use 1
• The 2015 ESC guidelines for the management of patients with ventricular arrhythmias similarly contraindicate propafenone in patients with Brugada syndrome 1
• The 2024 ESC guidelines for atrial fibrillation management reinforce that Class IC antiarrhythmic drugs (including propafenone) should be avoided in Brugada syndrome 1

Alternative Medications for Brugada Syndrome

• Quinidine is the preferred antiarrhythmic medication for Brugada syndrome patients experiencing recurrent ICD shocks or those who are not candidates for an ICD 1
• For patients with symptomatic Brugada syndrome who decline or are not candidates for an ICD, catheter ablation may be considered as an alternative to quinidine 1
• Beta-blockers may be used in Brugada syndrome patients but are primarily indicated for catecholaminergic polymorphic ventricular tachycardia rather than Brugada syndrome itself 1

Clinical Implications and Monitoring

• Patients with Brugada syndrome should be screened for all medications that may exacerbate their condition, as approximately one-third of Brugada syndrome patients are prescribed contraindicated medications after diagnosis 3
• Propafenone has been documented to fail to identify Brugada syndrome in drug challenge tests, while ajmaline successfully unmasked the condition in the same patient, indicating propafenone's unreliability for diagnostic purposes 4
• Healthcare providers should maintain heightened awareness of medication contraindications in Brugada syndrome patients, as prescription patterns often do not change even after diagnosis 3

Important Caveats

• The "pill-in-pocket" approach using propafenone for paroxysmal atrial fibrillation is specifically contraindicated in patients with Brugada syndrome 5
• Even medications with theoretical risk (such as propafenone) should be strictly avoided in Brugada syndrome patients, as the consequences of arrhythmia can be fatal 6
• Female patients with Brugada syndrome may be at higher risk of receiving contraindicated medications like propafenone, as they are more likely to be prescribed non-recommended drugs after diagnosis 3