Asymptomatic Brugada patients: long-term prognosis from a large prospective study

Abstract

Abstract Background One of the greatest challenges concerning the Brugada syndrome is how to stratify and manage asymptomatic patients, who represent the majority of patients with Brugada ECG pattern (BrECG). Purpose Aim of our study was to evaluate the long-term prognosis of a large population of asymptomatic Brugada patients. Methods One thousand one hundred and forty-nine asymptomatic Brugada patients were collected. Patients were treated as follows: in the 539 subjects with spontaneous type 1 BrECG documented on basal ECG or at 12-lead 24-hour Holter monitoring (12L-Holter) an electrophysiological study (EPS) was proposed and ICD implantation was proposed on the basis of the EPS results; in the 610 subjects with drug-induced-only type 1, clinical follow-up with multiple ECGs and 12L-Holter was suggested to search for spontaneous type 1 BrECG. Results Over a median follow-up of 6 (4-9) years there were 17 arrhythmic events (1.5%). Sixteen events occurred in the 539 patients with spontaneous type 1 (3%; 0.4% person-years) and only 1 in the 610 patients with drug-induced type 1 BrECG (0.16%; 0.03% person-years, p 0.001). Patients with spontaneous type 1 had a 15-time higher risk of arrhythmic events than patients with drug- induced type 1 BrECG. Patients with spontaneous type 1 BrECG and positive EPS had a 3-time higher risk of arrhythmic events than patients with negative EPS (6.8% vs 1.6%, p 0.035). An ICD was implanted in 163 patients: 8 (5%) received an appropriate intervention, while 23% experienced device-related complications, including 1 death. Conclusions Asymptomatic patients with spontaneous type 1 BrECG have an event rate of 3% at a median follow-up of 6 years. In this group, EPS represents a useful risk stratification procedure, as a positive EPS identifies patients with a 3-time higher event rate as compared to subjects with negative EPS. A negative EPS identifies a population at low although not zero-risk. Asymptomatic patients with drug-induced only Brugada ECG pattern are a group at very low arrhythmic risk. ICD implantation is burdened by a high incidence of complications, therefore alternative therapeutic strategies are needed.