What is the immediate management for a patient with symptomatic syncope and a history of Brugada syndrome in the Emergency Room (ER)?

Immediate ER Management of Symptomatic Syncope in Brugada Syndrome

Admit the patient immediately to a monitored bed with continuous telemetry and prepare for ICD evaluation, as syncope in Brugada syndrome is presumed arrhythmic until proven otherwise. 1

Initial Assessment and Stabilization

Immediate Actions

• Place on continuous cardiac telemetry monitoring to detect ventricular arrhythmias or bradyarrhythmias 2, 3
• Obtain 12-lead ECG with high electrode positioning (second and third intercostal spaces) to confirm spontaneous type 1 Brugada pattern: coved ST-segment elevation ≥2 mm in V1 and/or V2 with negative T-waves 1, 4
• Check temperature and treat fever aggressively with antipyretics if present, as fever can acutely precipitate cardiac arrest in Brugada syndrome 1, 4, 5
• Review all medications immediately and discontinue sodium channel blockers, QT-prolonging drugs, psychotropic agents, and anesthetic agents that may trigger ventricular fibrillation 1, 4, 5

Critical History Elements

• Document syncope characteristics: prodromal symptoms (typically absent or brief in arrhythmic syncope), position during event (supine or during exertion suggests cardiac cause), witness account of seizure-like activity, and recovery phase 1, 6
• Identify high-risk features: family history of sudden cardiac death, previous cardiac arrest, recurrent syncope episodes, and syncope during sleep or at rest 1, 4
• Assess for alternative causes: recent alcohol excess, cocaine use, or situational triggers that might suggest vasovagal syncope 1, 5

Physical Examination Priorities

• Complete cardiovascular examination for structural heart disease, murmurs, or signs of heart failure 6
• Orthostatic vital signs to exclude orthostatic hypotension as alternative diagnosis 6
• Neurological examination to identify focal deficits that would suggest alternative diagnosis 1

Risk Stratification and Disposition

High-Risk Features Mandating Admission

This patient meets Class I criteria for ICD evaluation based on spontaneous type 1 ECG pattern with recent syncope presumed due to ventricular arrhythmia 1, 4

The annual arrhythmic event rate in Brugada patients with syncope is 3.2% compared to 13.5% in cardiac arrest survivors and 1% in asymptomatic patients 4, 5

Diagnostic Testing in ER

• Targeted laboratory tests only: electrolytes, renal function if dehydration suspected, but avoid comprehensive panels without indication 6
• Echocardiography to exclude structural heart disease if not previously documented 1, 6
• Do NOT order: routine brain imaging (CT/MRI), EEG, or carotid ultrasound unless focal neurological findings present 1, 6

Definitive Management Plan

ICD Implantation (Class I Recommendation)

ICD implantation is recommended if meaningful survival greater than 1 year is expected, as this is the only proven therapy to prevent sudden cardiac death 1, 4, 5

Alternative Management if ICD Declined or Contraindicated

• Quinidine (Class I recommendation for patients who decline or are not candidates for ICD) 1, 4
• Catheter ablation of right ventricular outflow tract as alternative option 1, 5

Role of Electrophysiology Study

EP study with programmed ventricular stimulation may be considered (Class IIb) for further risk stratification, though its utility remains debated 1

However, implantable loop recorder (ILR) can be useful in select cases where syncope mechanism remains unclear, particularly to exclude vasovagal syncope or bradyarrhythmias before committing to ICD 2, 3

Critical Pitfalls to Avoid

Common Diagnostic Errors

• Do not assume vasovagal syncope even if patient is young or has prodromal symptoms—arrhythmic syncope in Brugada often has minimal or absent prodrome 3
• Do not discharge without telemetry monitoring even if patient appears stable, as ventricular arrhythmias can occur unpredictably 4, 3
• Do not order drug-induced type 1 pattern testing in ER if spontaneous type 1 pattern already present—this is unnecessary and potentially dangerous 1

Medication Safety

• Avoid: sodium channel blockers (Class IA and IC antiarrhythmics), certain psychotropic medications, cocaine, and excessive alcohol 1, 4, 5
• Treat fever immediately as it can unmask or worsen Brugada pattern and precipitate ventricular fibrillation 1, 4, 5

Disposition and Follow-Up

Admission Criteria (All Met in This Case)

• Spontaneous type 1 Brugada pattern with syncope requires admission to monitored bed 1, 4
• Cardiology/electrophysiology consultation for ICD evaluation during hospitalization 1, 4
• Family screening should be initiated with genetic counseling (Class IIb recommendation) 1, 4

If ICD Implanted

• Monitor for device complications: inappropriate shocks, infection, psychological impact 7
• Consider quinidine or ablation if recurrent ICD shocks occur (Class I recommendation) 1, 4