Asymptomatic Brugada syndrome: a cardiac ticking time-bomb?

‘You have a ticking time-bomb in your body’ is an expression too commonly used by cardiovascular surgeons when counseling patients with asymptomatic aortic aneurysm. Such patients find it difficult to cope with their ‘ticking-bomb’ dilemma—which sooner or later may blow-out their aorta— and often opt for invasive therapy before the ‘risk-vs.benefits’ section of the discussion is over. Based on the growing number of patients undergoing cardioverter defibrillator (ICD) implantation because of ‘asymptomatic Brugada syndrome with inducible ventricular fibrillation (VF),’ it appears that many cardiologists have adopted a ticking-bomb approach. Such aggressive approach was driven by studies by Brugada et al. convincingly showing (i) that a high percentage of asymptomatic patients with Brugada syndrome develop spontaneous VF within 3 years of diagnosis and (ii) that electrophysiologic studies (EPS) identify patients at risk for this potentially lethal outcome. More recent studies, however, do not confirm these observations. In this issue of the European Heart Journal, Paul et al. report a meta-analysis of Brugada syndrome that will force clinicians to pause and reevaluate the evidence supporting current practices. Paul et al. carefully reviewed the literature and painstakingly contacted the authors of every study reporting on EPS in Brugada syndrome. They were able to compare data from .400 patients included in the ‘Brugada Series‘ (which is the largest data-base reported by Brugada et al.), with data from .700 patients included in 15 different studies, referred to here as ‘theother studies.’ Themainfindings of Paul’s analysis are: (i) patients included in the Brugada Series have higher inducibility rates during EPS than patients included in all ‘the other studies‘ (Figure 1); (ii) the high rate of spontaneous arrhythmic events reported in the Brugada Series was not observed in the other studies, explaining why other studies failed to reproduce the high positive predictive value for EPS (Figure 2).