Brugada sign: a normal variant or a bad omen? Insights for risk stratification and prognostication.

Brugada Syndrome is a relatively new clinical electro cardiographic entity with inordinate risk of sudden death in the absence of structural heart disease. However, the Brugada type of ECG changes have been known for almost half a century and observed in many asymptomatic individuals.1 Recommendations for such individuals in the literature are rather conflicting. Although some authors use the term asymptomatic Brugada syndrome, the relationship between asymptomatic patients with typical ECG abnormalities and clinical cases of Brugada syndrome is not clear. Indeed, the Brugada pattern may also be provoked by right ventricular pathology, by drugs (e.g., Class I A, C anti-arrhythmic drugs, tri-cyclic antidepressants, overdose of psychotropic agents and analgesics that exhibit sodium channel blocking properties) and can be associated with electrolyte abnormalities (i.e., hyperkalaemia and hypercalcaemia). In Brugada syndrome, affected individuals can usually be detected by the typical ECG pattern, although not all patients have such an ECG and can only be diagnosed by drug challenges with IV ajmaline, flecainide or procainamide. In a recent review, a systematic literature search was performed in order to identify publications on the Brugada syndrome and the Brugada sign with special emphasis on analysing the outcome data.2 There have been two kinds of studies on the prognostic value and natural history of Brugada sign. In the first group of studies, the prevalence and outcome of the Brugada sign have been investigated