What is the primary treatment for a patient with Brugada syndrome, particularly those with a history of cardiac arrest or syncope?

Brugada Syndrome: Primary Treatment

An implantable cardioverter-defibrillator (ICD) is the only proven therapy to prevent sudden cardiac death in Brugada syndrome patients with cardiac arrest or syncope, and should be implanted in all such patients with meaningful survival greater than 1 year expected. 1, 2

High-Risk Patients Requiring ICD

The following patients with Brugada syndrome have Class I (strongest) recommendations for ICD implantation:

• Cardiac arrest survivors – ICD is mandatory regardless of ECG pattern 1, 2
• Spontaneous type 1 ECG pattern with syncope presumed due to ventricular arrhythmia – ICD should be implanted as syncope carries a 3.2% annual arrhythmic event rate compared to 13.5% in cardiac arrest survivors 1, 3
• Documented spontaneous sustained ventricular tachycardia – ICD is required 1

The spontaneous type 1 Brugada pattern (coved ST-segment elevation ≥2 mm in V1/V2 with negative T-waves) carries significantly worse prognosis than drug-induced pattern and is critical for risk stratification. 2, 3

Alternative Therapies for ICD-Ineligible Patients

Quinidine is the recommended alternative for patients who decline ICD or have contraindications, as it suppresses the Ito current and reduces ventricular fibrillation inducibility during programmed ventricular stimulation. 1, 2 This is a Class I recommendation from both European and American guidelines. 1

Catheter ablation of the right ventricular outflow tract is also recommended as an alternative option for ICD-ineligible patients. 1, 2, 3

Management of Recurrent ICD Shocks

For patients experiencing electrical storms or repeated appropriate ICD shocks, intensification of therapy with quinidine or catheter ablation is mandatory (Class I recommendation). 1, 2 Epicardial catheter ablation over the anterior right ventricular outflow tract may prevent electrical storms in patients with recurring episodes. 1, 2

Asymptomatic Patients

Observation without therapy is recommended for asymptomatic patients with only inducible type 1 Brugada pattern, as they have only a 1% annual arrhythmic event rate. 1, 2

Electrophysiological study with programmed ventricular stimulation may be considered (Class IIb) for further risk stratification in asymptomatic patients with spontaneous type 1 pattern, though its prognostic value remains debated. 1

Essential Lifestyle Modifications for All Patients

Regardless of treatment strategy, all Brugada syndrome patients must implement these lifestyle changes (Class I recommendation):

• Strict avoidance of contraindicated medications including sodium channel blockers (flecainide, ajmaline, procainamide), certain psychotropics, and QT-prolonging agents – refer patients to www.brugadadrugs.org 1, 2, 4
• Aggressive treatment of fever with antipyretics as fever can acutely precipitate cardiac arrest 1, 2, 3, 4
• Avoidance of excessive alcohol intake and large meals which can trigger ventricular fibrillation 1, 2, 4

Important Caveats About ICD Therapy

While ICD is life-saving, device-related complications are substantial in Brugada syndrome patients. Large multicenter studies show:

• Inappropriate shocks occur in 18-27% of patients, often 2.5 times more frequent than appropriate shocks 5, 6, 7
• Device-related complications occur in 28-32% of patients including lead failure, T-wave oversensing, and need for psychiatric assistance 5, 6, 7
• Annual complication rate is 8.9% 6

Subcutaneous ICD (S-ICD) is emerging as a viable alternative to transvenous ICD, with recent 2025 data showing appropriate shock delivery in 3% of patients with 90% first-shock success rate and lower complication rates (4% device-related complications). 8 However, full screening including exercise testing and drug provocation challenge is essential before S-ICD selection. 9, 8

Notably, in patients without prior cardiac arrest (including those with syncope or inducible VF), appropriate ICD therapy rates are significantly lower – some studies show zero appropriate shocks during 39-month follow-up in non-cardiac arrest patients. 5 This underscores the importance of careful patient selection and shared decision-making regarding device implantation, particularly given the high complication rates.