Brugada type 1 electrocardiogram: Should we treat the electrocardiogram or the patient?

Patients with a Brugada type 1 electrocardiogram (ECG) pattern may suffer sudden cardiac death (SCD). Recognized risk factors are spontaneous type 1 ECG and syncope of presumed arrhythmic origin. Familial sudden cardiac death (f-SCD) is not a recognized independent risk factor. Finally, positive electrophysiologic study (+EPS) has a controversial prognostic value. Current ESC guidelines recommend implantable cardioverter defibrillator (ICD) implantation in patients with a Brugada type 1 ECG pattern if they have suffered a previous resuscitated cardiac arrest (class I recommendation) or if they have syncope of presumed cardiac origin (class IIa recommendation). In clinical practice, however, many other patients undergo ICD implantation despite the suggestions of the guidelines. In a 2014 cumulative analysis of the largest available studies (including over 2000 patients), we found that 1/3 of patients received an ICD in primary prevention. Interestingly, 55% of these latter were asymptomatic, while 80% had a + EPS. This means that over 30% of subjects with a Brugada type 1 ECG pattern were considered at high risk of SCD mainly on the basis of EPS, to which a class IIb indication for ICD is assigned by the current ESC guidelines. Follow-up data confirm that in clinical practice single, and often frail, risk factors overestimate the real risk in subjects with the Brugada type 1 ECG pattern. We can argue that, in clinical practice, many cardiology centers adopt an aggressive treatment in subjects with a Brugada type 1 ECG pattern who are not at high risk. As a result, many healthy persons may be treated in order to save a few patients with a true Brugada Syndrome. Better risk stratification is needed. A multi-parametric approach that considers the contemporary presence of multiple risk factors is a promising one.

Citation

Pietro Delise, Giuseppe Allocca, Nadir Sitta. Brugada type 1 electrocardiogram: Should we treat the electrocardiogram or the patient? World journal of cardiology. 2017 Sep 26;9(9):737-741

PMID: 29081906

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