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Asymptomatic Brugada – A Silent Danger

November 30, 2023

Written by Megan Hilbert

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Risk stratification of patients with asymptomatic Brugada remains a clinical dilemma and makes expectant guidance difficult. This article has demonstrated the highest risk of arrythmia in those with spontaneous type-1 BrECG (Brugada ECG) as compared to those with drug-induced-only BrECG.

Note: For ease of reading, further mention of these subtypes will be shortened to spontaneous and drug-induced respectively

I’m channeling my best salty come-back
80% of patients with Brugada syndrome are asymptomatic until the occurrence of sudden cardiac dysrhythmias and potential death. Identification of this etiology early on via ECG remains paramount. Of patients with spontaneous BrECG there is a 0.4% risk of arrhythmia as compared to drug-induced-only BrECG which carries a risk of 0.03% per year. Patient’s with spontaneous subtype that undergo and have a positive electrophysiologic study (EPS) have a further increased risk of arrhythmia to their EPS-negative counterparts. Risk in the spontaneous subtype with positive EPS further increases to 2% at 5 years and 5% at 10 years. Kudos to the authors for following this patient population for such an extended period of time!

We are inundated with ECGs in the ER. Often we are the first to identify concerning ECG findings, particularly in the younger patient population. This article highlights the importance of identifying these patients and making sure to facilitate appropriate work-up given that risk of arrhythmia continues to increase over time.

How will this change my practice?
While it may be easy to brush off an asymptomatic patient with Brugada pattern on ECG, this article highlights the non-negligible risk of arrhythmia over time and necessitates our vigilance as emergency physicians to make sure that this patient population has the appropriate EP follow-up evaluation and counseling on risk reduction strategies.

Source
Asymptomatic Patients With Brugada ECG Pattern: Long-Term Prognosis From a Large Prospective Study. Circulation. 2023 Nov 14;148(20):1543-1555. doi: 10.1161/CIRCULATIONAHA.123.064689. Epub 2023 Oct 13.

Editor’s note: Dr. Brugada says that a Brugada type 1 (“coved type”) ECG consists of, “ST-segment elevation ≥2 mm in ≥1 right precordial lead (V1 to V3), followed by an r’-wave and a concave or straight ST segment. The descending ST segment crosses the isoelectric line and is followed by a negative and symmetric T-wave.” Type 2 has a saddle-back appearance, with convex ST elevation, upright T wave, and some additional criteria shown and discussed in the open access JACC article below. ~Clay Smith

Image from: Brugada J, Campuzano O, Arbelo E, Sarquella-Brugada G, Brugada R. Present Status of Brugada Syndrome: JACC State-of-the-Art Review. J Am Coll Cardiol. 2018 Aug 28;72(9):1046-1059. doi: 10.1016/j.jacc.2018.06.037.

What are your thoughts?