Risk stratification in Brugada syndrome: Clinical characteristics, electrocardiographic parameters, and auxiliary testing

Risk stratification in Brugada syndrome remains a clinical challenge because the event rate is low but the presenting symptom is often cardiac arrest (CA). We review the data on risk stratification. A history of CA or malignant syncope is a strong predictor of spontaneous ventricular fibrillation (VF), whereas the prognostic value of a history of familial sudden death and the presence of a SCN5A mutation are less well defined. On the electrocardiogram, the presence of spontaneous type I electrocardiogram increases the risk for VF in all studies, whereas the presence of fragmented QRS complexes and early repolarization correlates with increased risk in several studies. Signal-averaged techniques using late potentials and microscopic T-wave alternans show some promising results in small studies that need to be confirmed. The value of electrophysiologic studies for predicting spontaneous VF remains controversial, and this includes programmed stimulation protocols that avoid a third extrastimuli or stimulation from the right ventricular outflow. Risk prediction is particularly challenging in children and women.