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Asymptomatic Patients With Brugada ECG Pattern
Quick Takes
- Asymptomatic patients with Brugada ECG pattern demonstrate a low incidence of arrhythmic events (0.2% per year), and the arrhythmic risk is extremely low in the patients with the true drug induced–only Brugada ECG (0.03% per year).
- The presence of spontaneous type-1 Brugada ECG associated with positive EP study identifies a subgroup of patients with higher arrhythmic risk.
Study Questions:
What is the long-term prognosis of asymptomatic patients with Brugada electrocardiogram (ECG) pattern (BrECG)?
Methods:
The authors analyzed data on asymptomatic patients with BrECG (1,149) from two Italian centers. The subjects were followed for 2 to 22 years. For the 539 asymptomatic patients with spontaneous type 1 documented on baseline ECG (87%) or 12-lead 24-hour Holter monitoring (13%), an electrophysiologic study (EPS) was proposed. For the remaining 610 patients with drug-induced–only type 1, multiple ECGs and 12-lead Holter were advised in order to detect the occurrence of a spontaneous type-1 BrECG pattern. Arrhythmic events were defined as sudden death or documented ventricular fibrillation or tachycardia.
Results:
Median follow-up was 6 years. Seventeen (1.5%) arrhythmic events occurred in the overall asymptomatic population (corresponding to an event rate of 0.2% per year), including 16 of 539 (0.4% per year) in patients with spontaneous type-1 BrECG and 1 of 610 in those with drug-induced type-1 BrECG (0.03% per year; p < 0.001). EPS was performed in 339 (63%) patients with spontaneous type-1 BrECG. Patients with spontaneous type-1 BrECG and positive EPS had significantly higher event rates than patients with negative EPS (0.7% per year vs. 0.2% per year, p = 0.025). Among 200 patients who declined EPS, five events (0.4% per year) occurred. There was one device-related death.
Conclusions:
The authors conclude that the entire population of asymptomatic patients with BrECG exhibits a low event rate. The presence of spontaneous type-1 BrECG associated with positive EPS identifies a subgroup at higher risk. Asymptomatic patients with drug-induced–only BrECG have a minimal arrhythmic risk, but ongoing follow-up with 12-lead Holter monitoring is recommended.
Perspective:
There is a consensus on the treatment of symptomatic patients with Brugada syndrome, including patients with a previous history of aborted sudden death or arrhythmic syncope, for whom an implantable cardioverter-defibrillator is indicated. However, there is a much larger group of asymptomatic patients with Brugada pattern on ECG, and their management has been controversial. Importantly, 80% of patients with sudden death are asymptomatic until the occurrence of the event.
In the present study, the authors show that among asymptomatic patients in whom the spontaneous type-1 BrECG pattern was searched and excluded with repeat at least annual ECG and 12-lead 24-hour Holter (i.e., those with a true drug-induced–only type-1 ECG), the event rate is extremely low (0.03% per year). On the other hand, patients with spontaneous type-1 BrECG pattern have a significantly greater risk for arrhythmia. It is important to remember that patients with a positive drug test should be provided with lifesaving behavioral recommendations and made aware of the need for regular follow-up visits, each with repeat ECGs and 12-lead 24-hour Holter monitoring to detect the appearance of a spontaneous type-1 BrECG pattern.
Clinical Topics: Arrhythmias and Clinical EP, Implantable Devices, Genetic Arrhythmic Conditions, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Brugada Syndrome, Electrocardiography, Electrophysiology
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