Brugada syndrome treatment

Jump to: navigation, search

Brugada syndrome Microchapters


Patient Information


Historical Perspective



Differentiating Brugada syndrome from other Diseases

Epidemiology and Demographics

Risk Factors


Natural History, Complications and Prognosis


Diagnostic Criteria

History and Symptoms

Physical Examination

Laboratory Findings


Examples of Type I Brugada Syndrome

Chest X Ray

Echocardiography or Ultrasound

Electrophysiologic Studies

Genetic Testing



Drugs to Avoid

Drugs to Preferably Avoid

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Brugada syndrome treatment On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides


American Roentgen Ray Society Images of Brugada syndrome treatment

All Images
Echo & Ultrasound
CT Images

Ongoing Trials at Clinical

US National Guidelines Clearinghouse

NICE Guidance

FDA on Brugada syndrome treatment

CDC on Brugada syndrome treatment

Brugada syndrome treatment in the news

Blogs on Brugada syndrome treatment

Directions to Hospitals Treating Brugada syndrome

Risk calculators and risk factors for Brugada syndrome treatment

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sogand Goudarzi, MD [2]


Implantation of a cardiac defibrillator is the only proven method of treatment in Brugada syndrome.Patients with aborted sudden cardiac death are at high risk for recurrence and should undergo AICD implantation, and do not require an electrophysiologic study to assess inducibility. Patients with symptoms (either syncope, seizures or nocturnal agonal respirations) should undergo implantation of a defibrillator if no other cause of their symptoms can be identified. Asymptomatic patients should undergo electrophysiologic testing, and if VT / VF can be induced, they should undergo implantation of an ICD. Asymptomatic patients who cannot be induced should followed-up closely. Patients who are asymptomatic with no family history of Brugada syndrome can be followed-up closely.

The Two Patient Groups

Patients divides patients into two groups:[1]

  • Higher risk patients with spontaneous Type I Brugada pattern
  • A less high risk cohort of patients who require infusion of a sodium channel blocker to induce a Type I Brugada pattern.

The management of these two groups of patients will be discussed separately.

Management of Patients with a Spontaneous Type I Brugada Pattern

Implantation of a cardiac defibrillator should be considered in the following patients:[2]

Symptomatic Patients

Asymptomatic Patients

In essence, if VT VF can be induced on electrophysiologic testing in these patients, a cardiac defibrillator should be implanted. It is unclear if the same recommendations apply to those patients who require that the electrodes be placed one to two intercostal spaces higher to demonstrate a Brugada type I electrocardiographic pattern.

Management of Patients with a Sodium Channel Induced Type I Brugada Pattern

Implantation of a cardiac defibrillator should be considered in the following patients:[4]

Symptomatic Patients


Asymptomatic Patients



  • Pharmacotherapy alone may not be sufficient to treat Brugada syndrome, but it may be required in regions of the world where ICD implantation is cost prohibitive or in infants.[6]

Drugs with Potential Antiarrhythmic Effect

Generic name Brand name® Class / Clinical use References Recommendation
Cilostazol e.g.
Phosphodiesterase inhibitor Tsuchiya 2002
Abud 2006
Matsui 1999
Class IIb
Beta-adrenergic receptor stimulation Miyazaki 1996
Suzuki 2000
Watanabe 2006
Ohgo 2007
Ganesan 2006
Class I
Orciprenaline e.g.
Beta-adrenergic receptor stimulation Kyriazis 2009 Class IIa
Quinidine e.g.
Antiarrhythmic Agent Suzuki 2000
Alings 2001
Belhassen 2004
Mizusawa 2006
Probst 2007
Ohgo 2007
Yan 1999
Class I
  • Recommendation: Class I: convincing evidence/opinion; Class IIa: evidence/opinion less clear; Class IIb: conflicting evidence/opinion; Class III: very little evidence.

Treatment of VT Storm

  • VT storm has been successfully treated with isoproterenol. The mechanism is thought to be augmenting the cardiac L type channel.[14]

Treatment of Coronary Ischemia

Treatment of Factors that may Precipitate Brugada Type EKG Changes and Clinical Symptoms

Contraindicated medications

Brugada syndrome is considered an absolute contraindication to the use of the following medications:

ACC/AHA/ESC 2017 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT)[19]

Recommendations for Brugada Syndrome

Class I
Suggested phrases for writing recommendations:

1. In asymptomatic patients with only inducible type 1 Brugada electrocardiographic pattern, observation without therapy is recommended.[20][21]

2. In patients with Brugada syndrome with spontaneous type 1 Brugada electrocardiographic pattern and cardiac arrest, sustained VA or a recent history of syncope presumed due to VA, an ICD is recommended if meaningful survival of greater than 1 year is expected.[22][23]

3. In patients with Brugada syndrome experiencing recurrent ICD shocks for polymorphic VT, intensification of therapy with quinidine or catheter ablation is recommended.[24][25]

4. In patients with spontaneous type 1 Brugada electrocardiographic pattern and symptomatic VA who either are not candidates for or decline an ICD, quinidine or catheter ablation is recommended.[24][26][25]

Class IIa
In patients with suspected long QT syndrome, ambulatory electrocardiographic monitoring, recording the ECG lying and immediately on standing, and/or exercise treadmill testing can be useful for establishing a diagnosis and monitoring the response to therapy.[27][28]
Class IIb
In patients with asymptomatic Brugada syndrome and a spontaneous type 1 Brugada electrocardiographic pattern, an electrophysiological study with programmed ventricular stimulation using single and double extrastimuli may be considered for further risk stratification.[20][23][29][30][31]
In patients with suspected or established Brugada syndrome, genetic counseling and genetic testing may be useful to facilitate cascade screening of relatives.[32][33]


  1. Batchvarov VN (December 2014). "The Brugada Syndrome - Diagnosis, Clinical Implications and Risk Stratification". Eur Cardiol. 9 (2): 82–87. doi:10.15420/ecr.2014.9.2.82. PMC 6159405. PMID 30310491.
  2. Abu Sham'a RA, Kufri FH, Yassin IH (2007). "Brugada syndrome: an unusual cause of syncope in a young patient". Ann Saudi Med. 27 (3): 201–5. doi:10.5144/0256-4947.2007.201. PMC 6077086. PMID 17568171.
  3. Pappone C, Santinelli V (March 2019). "Brugada Syndrome: Progress in Diagnosis and Management". Arrhythm Electrophysiol Rev. 8 (1): 13–18. doi:10.15420/aer.2018.73.2. PMC 6434501. PMID 30918662.
  4. Swe T, Dogar MH (2016). "Type 1 Brugada pattern electrocardiogram induced by hypokalemia". J Family Med Prim Care. 5 (3): 709–711. doi:10.4103/2249-4863.197295. PMC 5290792. PMID 28217615.
  5. Pappone C, Santinelli V (March 2019). "Brugada Syndrome: Progress in Diagnosis and Management". Arrhythm Electrophysiol Rev. 8 (1): 13–18. doi:10.15420/aer.2018.73.2. PMC 6434501. PMID 30918662.
  6. Al-Khatib, Sana M.; Stevenson, William G.; Ackerman, Michael J.; Bryant, William J.; Callans, David J.; Curtis, Anne B.; Deal, Barbara J.; Dickfeld, Timm; Field, Michael E.; Fonarow, Gregg C.; Gillis, Anne M.; Granger, Christopher B.; Hammill, Stephen C.; Hlatky, Mark A.; Joglar, José A.; Kay, G. Neal; Matlock, Daniel D.; Myerburg, Robert J.; Page, Richard L. (2018). "2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death". Circulation. 138 (13). doi:10.1161/CIR.0000000000000549. ISSN 0009-7322.
  7. Belhassen B, Glick A, Viskin S (2004). "Efficacy of quinidine in high-risk patients with Brugada syndrome". Circulation. 110 (13): 1731–7. doi:10.1161/01.CIR.0000143159.30585.90. PMID 15381640.
  8. Tsuchiya, Takeshi; Ashikaga, Keiichi; Honda, Toshihiro; Arita, Makoto (2002). "Prevention of Ventricular Fibrillation by Cilostazol, an Oral Phosphodiesterase Inhibitor, in a Patient with Brugada Syndrome". Journal of Cardiovascular Electrophysiology. 13 (7): 698–701. doi:10.1046/j.1540-8167.2002.00698.x. ISSN 1045-3873.
  9. Abud, Atilio; Bagattin, Daniel; Goyeneche, Raul; Becker, Carlos (2006). "Failure of Cilostazol in the Prevention of Ventricular Fibrillation in a Patient with Brugada Syndrome". Journal of Cardiovascular Electrophysiology. 17 (2): 210–212. doi:10.1111/j.1540-8167.2005.00290.x. ISSN 1045-3873.
  10. Matsui, Kazunori; Kiyosue, Tatsuto; Wang, Jin-Cheng; Dohi, Kazuhiro; Arita, Makoto (1999). Cardiovascular Drugs and Therapy. 13 (2): 105–113. doi:10.1023/A:1007779908346. ISSN 0920-3206. Missing or empty |title= (help)
  11. Miyazaki, Toshihisa; Mitamura, Hideo; Miyoshi, Shunichiro; Soejima, Kyoko; Aizawa, Yoshifusa; Ogawa, Satoshi (1996). "Autonomic and antiarrhythmic drug modulation of ST segment elevation in patients with Brugada syndrome". Journal of the American College of Cardiology. 27 (5): 1061–1070. doi:10.1016/0735-1097(95)00613-3. ISSN 0735-1097.
  12. Suzuki, Hiroshi; Torigoe, Katsumi; Numata, Osamu; Yazaki, Satoshi (2000). "Infant Case with a Malignant Form of Brugada Syndrome". Journal of Cardiovascular Electrophysiology. 11 (11): 1277–1280. doi:10.1046/j.1540-8167.2000.01277.x. ISSN 1045-3873.
  13. Obeyesekere MN, Klein GJ, Modi S, Leong-Sit P, Gula LJ, Yee R, Skanes AC, Krahn AD (December 2011). "How to perform and interpret provocative testing for the diagnosis of Brugada syndrome, long-QT syndrome, and catecholaminergic polymorphic ventricular tachycardia". Circ Arrhythm Electrophysiol. 4 (6): 958–64. doi:10.1161/CIRCEP.111.965947. PMID 22203660.
  14. Argenziano M, Antzelevitch C (June 2018). "Recent advances in the treatment of Brugada syndrome". Expert Rev Cardiovasc Ther. 16 (6): 387–404. doi:10.1080/14779072.2018.1475230. PMC 6330094. PMID 29757020.
  15. Kujime S, Sakurada H, Saito N, Enomoto Y, Ito N, Nakamura K, Fukamizu S, Tejima T, Yambe Y, Nishizaki M, Noro M, Hiraoka M, Sugi K (2017). "Outcomes of Brugada Syndrome Patients with Coronary Artery Vasospasm". Intern. Med. 56 (2): 129–135. doi:10.2169/internalmedicine.56.7307. PMC 5337455. PMID 28090040.
  16. Amin, A. S.; Klemens, C. A.; Meregalli, P. G.; Asghari-Roodsari, A.; de Bakker, J. M. T.; January, C. T.; Wilde, A. A. M.; Tan, H. L. (2010). "Fever-triggered ventricular arrhythmias in Brugada syndrome and type 2 long-QT syndrome". Netherlands Heart Journal. 18 (3): 165–169. doi:10.1007/BF03091755. ISSN 1568-5888.
  17. Antzelevitch C, Brugada P, Brugada J, Brugada R (January 2005). "Brugada syndrome: from cell to bedside". Curr Probl Cardiol. 30 (1): 9–54. doi:10.1016/j.cpcardiol.2004.04.005. PMC 1475801. PMID 15627121.
  18. Swe T, Dogar MH (2016). "Type 1 Brugada pattern electrocardiogram induced by hypokalemia". J Family Med Prim Care. 5 (3): 709–711. doi:10.4103/2249-4863.197295. PMC 5290792. PMID 28217615.
  19. . doi:10.1161/CIR.000000000000054. Missing or empty |title= (help)
  20. 20.0 20.1 Casado-Arroyo R, Berne P, Rao JY, Rodriguez-Mañero M, Levinstein M, Conte G, Sieira J, Namdar M, Ricciardi D, Chierchia GB, de Asmundis C, Pappaert G, La Meir M, Wellens F, Brugada J, Brugada P (August 2016). "Long-Term Trends in Newly Diagnosed Brugada Syndrome: Implications for Risk Stratification". J. Am. Coll. Cardiol. 68 (6): 614–623. doi:10.1016/j.jacc.2016.05.073. PMID 27491905.
  21. Probst V, Veltmann C, Eckardt L, Meregalli PG, Gaita F, Tan HL, Babuty D, Sacher F, Giustetto C, Schulze-Bahr E, Borggrefe M, Haissaguerre M, Mabo P, Le Marec H, Wolpert C, Wilde AA (February 2010). "Long-term prognosis of patients diagnosed with Brugada syndrome: Results from the FINGER Brugada Syndrome Registry". Circulation. 121 (5): 635–43. doi:10.1161/CIRCULATIONAHA.109.887026. PMID 20100972.
  22. Priori SG, Gasparini M, Napolitano C, Della Bella P, Ottonelli AG, Sassone B, Giordano U, Pappone C, Mascioli G, Rossetti G, De Nardis R, Colombo M (January 2012). "Risk stratification in Brugada syndrome: results of the PRELUDE (PRogrammed ELectrical stimUlation preDictive valuE) registry". J. Am. Coll. Cardiol. 59 (1): 37–45. doi:10.1016/j.jacc.2011.08.064. PMID 22192666.
  23. 23.0 23.1 Sroubek J, Probst V, Mazzanti A, Delise P, Hevia JC, Ohkubo K, Zorzi A, Champagne J, Kostopoulou A, Yin X, Napolitano C, Milan DJ, Wilde A, Sacher F, Borggrefe M, Ellinor PT, Theodorakis G, Nault I, Corrado D, Watanabe I, Antzelevitch C, Allocca G, Priori SG, Lubitz SA (February 2016). "Programmed Ventricular Stimulation for Risk Stratification in the Brugada Syndrome: A Pooled Analysis". Circulation. 133 (7): 622–30. doi:10.1161/CIRCULATIONAHA.115.017885. PMC 4758872. PMID 26797467.
  24. 24.0 24.1 Belhassen B, Rahkovich M, Michowitz Y, Glick A, Viskin S (December 2015). "Management of Brugada Syndrome: Thirty-Three-Year Experience Using Electrophysiologically Guided Therapy With Class 1A Antiarrhythmic Drugs". Circ Arrhythm Electrophysiol. 8 (6): 1393–402. doi:10.1161/CIRCEP.115.003109. PMID 26354972.
  25. 25.0 25.1 Zhang P, Tung R, Zhang Z, Sheng X, Liu Q, Jiang R, Sun Y, Chen S, Yu L, Ye Y, Fu G, Shivkumar K, Jiang C (November 2016). "Characterization of the epicardial substrate for catheter ablation of Brugada syndrome". Heart Rhythm. 13 (11): 2151–2158. doi:10.1016/j.hrthm.2016.07.025. PMID 27453126.
  26. Nademanee K, Veerakul G, Chandanamattha P, Chaothawee L, Ariyachaipanich A, Jirasirirojanakorn K, Likittanasombat K, Bhuripanyo K, Ngarmukos T (March 2011). "Prevention of ventricular fibrillation episodes in Brugada syndrome by catheter ablation over the anterior right ventricular outflow tract epicardium". Circulation. 123 (12): 1270–9. doi:10.1161/CIRCULATIONAHA.110.972612. PMID 21403098.
  27. Antzelevitch C, Yan GX, Ackerman MJ, Borggrefe M, Corrado D, Guo J, Gussak I, Hasdemir C, Horie M, Huikuri H, Ma C, Morita H, Nam GB, Sacher F, Shimizu W, Viskin S, Wilde A (April 2017). "J-Wave syndromes expert consensus conference report: Emerging concepts and gaps in knowledge". Europace. 19 (4): 665–694. doi:10.1093/europace/euw235. PMC 5834028. PMID 28431071. Vancouver style error: initials (help)
  28. Somani R, Krahn AD, Healey JS, Chauhan VS, Birnie DH, Champagne J, Sanatani S, Angaran P, Gow RM, Chakrabarti S, Gerull B, Yee R, Skanes AC, Gula LJ, Leong-Sit P, Klein GJ, Gollob MH, Talajic M, Gardner M, Simpson CS (June 2014). "Procainamide infusion in the evaluation of unexplained cardiac arrest: from the Cardiac Arrest Survivors with Preserved Ejection Fraction Registry (CASPER)". Heart Rhythm. 11 (6): 1047–54. doi:10.1016/j.hrthm.2014.03.022. PMID 24657429.
  29. Delise P, Allocca G, Marras E, Giustetto C, Gaita F, Sciarra L, Calo L, Proclemer A, Marziali M, Rebellato L, Berton G, Coro L, Sitta N (January 2011). "Risk stratification in individuals with the Brugada type 1 ECG pattern without previous cardiac arrest: usefulness of a combined clinical and electrophysiologic approach". Eur. Heart J. 32 (2): 169–76. doi:10.1093/eurheartj/ehq381. PMC 3021386. PMID 20978016.
  30. Kusumoto, Fred M.; Bailey, Kent R.; Chaouki, Ahmad Sami; Deshmukh, Abhishek J.; Gautam, Sandeep; Kim, Robert J.; Kramer, Daniel B.; Lambrakos, Litsa K.; Nasser, Naseer H.; Sorajja, Dan (2018). "Systematic Review for the 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death". Circulation. 138 (13). doi:10.1161/CIR.0000000000000550. ISSN 0009-7322.
  31. Sieira J, Conte G, Ciconte G, de Asmundis C, Chierchia GB, Baltogiannis G, Di Giovanni G, Saitoh Y, Irfan G, Casado-Arroyo R, Juliá J, La Meir M, Wellens F, Wauters K, Van Malderen S, Pappaert G, Brugada P (August 2015). "Prognostic value of programmed electrical stimulation in Brugada syndrome: 20 years experience". Circ Arrhythm Electrophysiol. 8 (4): 777–84. doi:10.1161/CIRCEP.114.002647. PMID 25904495.
  32. Crotti L, Marcou CA, Tester DJ, Castelletti S, Giudicessi JR, Torchio M, Medeiros-Domingo A, Simone S, Will ML, Dagradi F, Schwartz PJ, Ackerman MJ (October 2012). "Spectrum and prevalence of mutations involving BrS1- through BrS12-susceptibility genes in a cohort of unrelated patients referred for Brugada syndrome genetic testing: implications for genetic testing". J. Am. Coll. Cardiol. 60 (15): 1410–8. doi:10.1016/j.jacc.2012.04.037. PMC 3624764. PMID 22840528.
  33. Risgaard B, Jabbari R, Refsgaard L, Holst AG, Haunsø S, Sadjadieh A, Winkel BG, Olesen MS, Tfelt-Hansen J (November 2013). "High prevalence of genetic variants previously associated with Brugada syndrome in new exome data". Clin. Genet. 84 (5): 489–95. doi:10.1111/cge.12126. PMID 23414114.