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Risk Stratification in Brugada Syndrome
Open accessAbstract
Objectives The PRELUDE (PRogrammed ELectrical stimUlation preDictive valuE) prospective registry was designed to assess the predictive accuracy of sustained ventricular tachycardia/ventricular fibrillation (VTs/VF) inducibility and to identify additional predictors of arrhythmic events in Brugada syndrome patients without history of VT/VF.Background Brugada syndrome is a genetic disease associated with increased risk of sudden cardiac death. Even though its value has been questioned, inducibility of VTs/VF is widely used to select candidates to receive a prophylactic implantable defibrillator, and its accuracy has never been addressed in prospective studies with homogeneous enrolling criteria.Methods Patients with a spontaneous or drug-induced type I electrocardiogram (ECG) and without history of cardiac arrest were enrolled. The registry included 308 consecutive individuals (247 men, 80%; median age 44 years, range 18 to 72 years). Programmed electrical stimulation was performed at enrollment, and patients were followed-up every 6 months.Results During a median follow-up of 34 months, 14 arrhythmic events (4.5%) occurred (13 appropriate shocks of the implantable defibrillator, and 1 cardiac arrest). Programmed electrical stimulation performed with a uniform and pre-specified protocol induced ventricular tachyarrhythmias in 40% of patients: arrhythmia inducibility was not a predictor of events at follow-up (9 of 14 events occurred in noninducible patients). History of syncope and spontaneous type I ECG (hazard ratio [HR]: 4.20), ventricular refractory period <200 ms (HR: 3.91), and QRS fragmentation (HR: 4.94) were significant predictors of arrhythmias.Conclusions Our data show that VT/VF inducibility is unable to identify high-risk patients, whereas the presence of a spontaneous type I ECG, history of syncope, ventricular effective refractory period <200 ms, and QRS fragmentation seem useful to identify candidates for prophylactic implantable cardioverter defibrillator.
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“A drug-induced type 1 ECG pattern has a lower risk of sudden death than a spontaneous type 1 response.”
From 2018 ESC Guidelines for the diagnosis and management of syncope (2018) · cites this paper as [371]
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“[73]; 6% event rate at 34 ± 44 months by Priori et al.[70]; 1% event rate after 40 ± 50 months and 30 ± 21 months of follow-up, respectively by Eckardt et al.”
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“Interestingly, analogous with what is seen in BrS (20), inducibility of VT/VF at PES is not an independent predictor of risk in SQTS.”
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Arrhythmogenic Right Ventricular Cardiomyopathy
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“A recent metaanalysis found a relation with events in asymptomatic and patients presenting with syncope but great controversy still exists around this topic.(8,14,15) Furthermore, as the risk of SD in BS patients persists lifelong, extended long-term follow-up is of great importance.”
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“The presence of fragmented QRS as a marker for altered intraventricular conduction has been shown to be a reliable marker for future major cardiac events.(17,29) Prevalence of fragmented QRS in our population was much lower than reported, probably reflecting differences in populations and/ or electrocardiographic reco…”
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“902) as well as spontaneous type 1 ECG, history of syncope, and short ventricular refractory periods [36].”
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A Primary Prevention Clinical Risk Score Model for Patients With Brugada Syndrome (BRUGADA-RISK)
Honarbakhsh, S., Providencia, R. A., García-Hernández, J., Martin, C. A., Hunter, R. J., Lim, W. Y., Kirkby, C., Graham, A. J., Sharifzadehgan, A., Waldmann, V., et al. (2020) · JACC. Clinical electrophysiology · doi:10.1016/j.jacep.2020.08.032 · Cited by 101
“Due to the controversial nature of programmed ventricular stimulation as a risk factor for VA/SCD in BrS (2,6,18,20,24), it is not strongly recommended in clinical guidelines (10); only 406 patients (37%) in the current cohort underwent programmed ventricular stimulation as in other published studies (24), and 66% und…”
ResultBrugada syndrome: Diagnosis, risk stratification and management
Gourraud, J., Barc, J., Thollet, A., Marec, H. L., & Probst, V. (2017) · Archives of cardiovascular diseases · doi:10.1016/j.acvd.2016.09.009 · Cited by 94
“QRS fragmentation At least four spikes in one or at least eight spikes in all of the precordial leads Increased risk, but needs to be confirmedb [10,40]”
BackgroundInfluentialThe ICD for Primary Prevention in Patients With Inherited Cardiac Diseases
Nordkamp, L. R. A. O., Wilde, A. A. M., Tijssen, J. G. P., Knops, R. E., van Dessel, P. F. H. M., & de Groot, J. R. (2012) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.112.975268 · Cited by 94
“Asymptomatic patients with BrS and inducible VT/VF with EPS and LQTS patients with only a family history of SCD are not considered for ICD implantation anymore.(24) The absence of prospective randomized studies makes it difficult to identify patients at risk, and risk factors for SCD and ICD indications have been deri…”
BackgroundGiustetto, C., Cerrato, N., Gribaudo, E., Scrocco, C., Castagno, D., Richiardi, E., Giachino, D. F., Bianchi, F., Barbonaglia, L., Ferraro, A., et al. (2013) · Heart Rhythm · doi:10.1016/j.hrthm.2013.10.043 · Cited by 95
Priori, S. G., Wilde, A. A. M., Horie, M., Cho, Y., Behr, E. R., Berul, C. I., Blom, N. A., Brugada, J., Chiang, C., Huikuri, H. V., et al. (2013) · Journal of Arrhythmia · doi:10.1016/j.joa.2013.08.001 · Cited by 90
“Since the first reporting, the reported annual rate of events has decreased.(27) –34 Several clinical variables have been demonstrated to predict a worse outcome in patients with BrS.”
Self-citationRelationship Between Arrhythmogenic Right Ventricular Cardiomyopathy and Brugada Syndrome
Corrado, D., Zorzi, A., Cerrone, M., Rigato, I., Mongillo, M., Bauce, B., & Delmar, M. (2016) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.115.003631 · Cited by 91
“tively investigated in the Programmed Electrical Stimulation Predictive Value (PRELUDE) study.(43)”
BackgroundAssessing the Malignant Ventricular Arrhythmic Substrate in Patients With Brugada Syndrome
Pappone, C., Ciconte, G., Manguso, F., Vicedomini, G., Mecarocci, V., Conti, M. A., Giannelli, L., Pozzi, P., Borrelli, V., Menicanti, L., et al. (2018) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2018.02.022 · Cited by 86
Self-citationLong-Term Trends in Newly Diagnosed Brugada Syndrome
Casado-Arroyo, R., Berne, P., Rao, J. Y., Rodríguez‐Mañero, M., Moisés Levinstein, J., Conte, G., Sieira, J. A., Namdar, M., Ricciardi, D., Chierchia, G., et al. (2016) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2016.05.073 · Cited by 85
“, 2002 (3) PRELUDE Registry, 2012 (10) Delise et al.”
BackgroundMilman, A., Gourraud, J., Andorin, A., Postema, P. G., Sacher, F., Mabo, P., Conte, G., Giustetto, C., Sarquella‐Brugada, G., Hochstadt, A., et al. (2018) · Heart Rhythm · doi:10.1016/j.hrthm.2018.06.019 · Cited by 82
Self-citationSieira, J. A., Ciconte, G., Conte, G., Chierchia, G., de Asmundis, C., Baltogiannis, G., Giovanni, G. D., Saitoh, Y., Irfan, G., Casado-Arroyo, R., et al. (2015) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.114.003044 · Cited by 82
“infrequent; none of the major BS registries have a mean follow-up >40 months.(10,11) As the risk of sudden death in patients”
BackgroundMilman, A., Andorin, A., Gourraud, J., Postema, P. G., Sacher, F., Mabo, P., Kim, S., Juang, J. J., Maeda, S., Takahashi, Y., et al. (2018) · Heart Rhythm · doi:10.1016/j.hrthm.2018.01.014 · Cited by 75
Self-citationPrognostic significance of fever-induced Brugada syndrome
Mizusawa, Y., Morita, H., Adler, A., Havakuk, O., Thollet, A., Maury, P., Wang, D. W., Hong, K., Gandjbakhch, E., Sacher, F., et al. (2016) · Heart Rhythm · doi:10.1016/j.hrthm.2016.03.044 · Cited by 76
Veerakul, G., & Nademanee, K. (2012) · Circulation Journal · doi:10.1253/circj.cj-12-1352 · Cited by 75
Ventricular Arrhythmias and Sudden Cardiac Death
Tang, P., Shenasa, M., & Boyle, N. G. (2017) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2017.08.004 · Cited by 76
Asymptomatic Patients With Brugada ECG Pattern: Long-Term Prognosis From a Large Prospective Study
Gaïta, F., Cerrato, N., Giustetto, C., Martino, A., Bergamasco, L., Millesimo, M., Barbonaglia, L., Carvalho, P., Caponi, D., Saglietto, A., et al. (2023) · Circulation · doi:10.1161/circulationaha.123.064689 · Cited by 75
“23,26 More recently, the metanalysis from Sroubek et al 27 demonstrated that induction of VT or VF at EPS was a marker of arrhythmic risk in the overall Brugada population; however, a consensus has not yet been reached.”
Li, K. H. C., Lee, S.-R., Yin, C.-S., Liu, T., Ngarmukos, T., Conte, G., Yan, G.-X., Sy, R., Letsas, K., & Tse, G. (2020) · International Journal of Cardiology: Heart & Vasculature · doi:10.1016/j.ijcha.2020.100468 · Cited by 69
Characterization and Management of Arrhythmic Events in Young Patients With Brugada Syndrome
Michowitz, Y., Milman, A., Andorin, A., Sarquella‐Brugada, G., Corcia, M. C. G., Gourraud, J., Conte, G., Sacher, F., Juang, J. J., Kim, S., et al. (2019) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2019.01.048 · Cited by 72
“5%) children (2), reports have mainly focused on adults who constitute the majority of symptomatic patients (3,4).”
BackgroundSelf-citationRisk Stratification in Patients With Brugada Syndrome Without Previous Cardiac Arrest
Okamura, H., Kamakura, T., Morita, H., Tokioka, K., Nakajima, I., Wada, M., Ishibashi, K., Miyamoto, K., Noda, T., Aiba, T., et al. (2014) · Circulation Journal · doi:10.1253/circj.cj-14-1059 · Cited by 70
About Brugada syndrome and its prevalence
Postema, P. G. (2012) · EP Europace · doi:10.1093/europace/eus042 · Cited by 69
“The most recent evidence in this debate comes from the Italian PRELUDE (PRogrammed ELectrical stimUlation preDictive valuE) study.(5) In this large prospective study, inducibility of arrhythmias had no additive value in asymptomatic patients—an important message to the community.”
BackgroundRollin, A., Sacher, F., Gourraud, J., Pasquié, J., Raczka, F., Duparc, A., Mondoly, P., Cardin, C., Delay, M., Chatel, S., et al. (2013) · Heart Rhythm · doi:10.1016/j.hrthm.2013.03.001 · Cited by 68
Mahida, S., Derval, N., Sacher, F., Leenhardt, A., Deisenhofer, I., Babuty, D., Schläpfer, J., Roy, L. D., Frank, R., Yli‐Mäyry, S., et al. (2015) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2014.10.043 · Cited by 67
“Age at first VF, yrs 36 13 Male/female 60/21 Family history of SCD 18/81 (22)”
BackgroundClinical characterisation and long-term prognosis of women with Brugada syndrome
Sieira, J. A., Conte, G., Ciconte, G., de Asmundis, C., Chierchia, G., Baltogiannis, G., Giovanni, G. D., Saitoh, Y., Irfan, G., Casado-Arroyo, R., et al. (2016) · Heart · doi:10.1136/heartjnl-2015-308556 · Cited by 67
Epidemiology of inherited arrhythmias
Offerhaus, J. A., Bezzina, C. R., & Wilde, A. A. M. (2019) · Nature Reviews Cardiology · doi:10.1038/s41569-019-0266-2 · Cited by 66
Inherited arrhythmias: The cardiac channelopathies
Behere, S. P., & Weindling, S. (2015) · Annals of Pediatric Cardiology · doi:10.4103/0974-2069.164695 · Cited by 66
“[15] Additionally, there are nontrivial false positive and false negative rates with EPT, as well as poor reproducibility.[17]”
BackgroundSingh, M., Morin, D. P., & Link, M. S. (2019) · Progress in Cardiovascular Diseases · doi:10.1016/j.pcad.2019.05.006 · Cited by 66
JCS/JHRS 2022 Guideline on Diagnosis and Risk Assessment of Arrhythmia
Takase, B., Ikeda, T., Shimizu, W., Abe, H., Aiba, T., Chinushi, M., Koba, S., KUSANO, K. F., Niwano, S., Takahashi, N., et al. (2023) · Circulation Journal · doi:10.1253/circj.cj-22-0827 · Cited by 68
Gray, B. R., Kirby, A. C., Kabunga, P., Freedman, S. B., Yeates, L., Kanthan, A., MEDI, C., KEECH, A. C., Semsarian, C., & Sy, R. W. (2017) · Heart Rhythm · doi:10.1016/j.hrthm.2017.02.026 · Cited by 62
Kawazoe, H., Nakano, Y., Ochi, H., Takagi, M., Hayashi, Y., Uchimura, Y., Tokuyama, T., Watanabe, Y., Matsumura, H., Tomomori, S., et al. (2016) · Heart Rhythm · doi:10.1016/j.hrthm.2016.07.009 · Cited by 60
The Brugada Syndrome: A Rare Arrhythmia Disorder with Complex Inheritance
Gourraud, J., Barc, J., Thollet, A., Scouarnec, S. L., Marec, H. L., Schott, J., Redon, R., & Probst, V. (2016) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2016.00009 · Cited by 62
Kusumoto, F. M., Bailey, K. R., Chaouki, A. S., Deshmukh, A. J., Gautam, S., Kim, R. J., Kramer, D. B., Lambrakos, L. K., Nasser, N. H., & Sorajja, D. (2017) · Heart Rhythm · doi:10.1016/j.hrthm.2017.10.037 · Cited by 59
Update on the Diagnosis and Management of Brugada Syndrome.
Vohra, J., & Rajagopalan, S. (2015) · Heart, Lung and Circulation · doi:10.1016/j.hlc.2015.07.020 · Cited by 56
“History of syncope, spontaneous Type 1 Brugada pattern, ERP <200msec and QRS fragmentation were predictive of increased risk [42].”
BackgroundTpeak–Tendinterval and Tpeak–Tend/QT ratio in patients with Brugada syndrome
Zumhagen, S., Zeidler, E. M., Stallmeyer, B., Ernsting, M., Eckardt, L., & Schulze‐Bahr, E. (2016) · EP Europace · doi:10.1093/europace/euw033 · Cited by 54
Kusumoto, F. M., Bailey, K. R., Chaouki, A. S., Deshmukh, A. J., Gautam, S., Kim, R. J., Kramer, D. B., Lambrakos, L. K., Nasser, N. H., & Sorajja, D. (2017) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2017.10.052 · Cited by 52
Cerrato, N., Giustetto, C., Gribaudo, E., Richiardi, E., Barbonaglia, L., Scrocco, C., Zema, D., & Gaita, F. (2015) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2014.10.007 · Cited by 48
on behalf of Fragmented QRS in Hypertrophic Obstructive Cardiomyopathy (FHOCM) Study Investigators, Femenía, F., Arce, M. A., Grieken, J. V., Trucco, E., Mont, L., Abello, M., Merino, J. L., Rivero‐Ayerza, M., Görenek, B., et al. (2013) · Journal of Interventional Cardiac Electrophysiology · doi:10.1007/s10840-013-9829-z · Cited by 49
Genetics of ion-channel disorders
Cerrone, M., Napolitano, C., & Priori, S. G. (2012) · Current Opinion in Cardiology · doi:10.1097/hco.0b013e328352429d · Cited by 49
Self-citationAge at diagnosis of Brugada syndrome: Influence on clinical characteristics and risk of arrhythmia
Minier, M., Probst, V., Berthome, P., Tixier, R., Briand, J., Geoffroy, O., Clémenty, N., Mansourati, J., Jesel, L., Dupuis, J., et al. (2019) · Heart Rhythm · doi:10.1016/j.hrthm.2019.11.027 · Cited by 49
Brugada syndrome: A general cardiologist's perspective
Polovina, M. M., VUKIĆEVIĆ, M., Banko, B., Lip, G. Y. H., & Potpara, T. (2017) · European Journal of Internal Medicine · doi:10.1016/j.ejim.2017.06.019 · Cited by 49
Letsas, K., Asvestas, D., Baranchuk, A., Liu, T., Georgopoulos, S., Efremidis, M., Korantzopoulos, P., Bazoukis, G., Tse, G., Sideris, A., et al. (2017) · Pacing and clinical electrophysiology : PACE · doi:10.1111/pace.13214 · Cited by 46
Kamakura, T., Wada, M., Nakajima, I., Ishibashi, K., Miyamoto, K., Okamura, H., Noda, T., Aiba, T., Takaki, H., Yasuda, S., et al. (2015) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.114.002705 · Cited by 47
“At the time of diagnosis (%) 3 (8) 5 (9) 3 (10) 0.”
Brugada Syndrome: Progress in Diagnosis and Management
Pappone, C., & Santinelli, V. (2019) · Arrhythmia & Electrophysiology Review · doi:10.15420/aer.2018.73.2 · Cited by 46
“Data suggest this latter group is at very low risk and that the presumed false-positive rate of pharmacological challenge is not trivial.(14) ECG should thus be routinely performed when a diagnosis of BrS is suspected but is uncertain on a standard ECG, and in screening family members of BrS patients (Figure 1).”
BackgroundSelf-citationUpdate on Brugada Syndrome 2019
Coppola, G., Corrado, E., Curnis, A., Maglia, G., Oriente, D., Mignano, A., & Brugada, P. (2019) · Current Problems in Cardiology · doi:10.1016/j.cpcardiol.2019.100454 · Cited by 48
Lee, S., Zhou, J., Li, K. H. C., Leung, K. S. K., Lakhani, I., Liu, T., Wong, I. C. K., Mok, N. S., Mak, C. M., Jeevaratnam, K., et al. (2021) · Open Heart · doi:10.1136/openhrt-2020-001505 · Cited by 45
Mazzanti, A., O’Rourke, S., Ng, K. K., Miceli, C., Borio, G., Curcio, A., Esposito, F., Napolitano, C., & Priori, S. G. (2014) · Expert Review of Cardiovascular Therapy · doi:10.1586/14779072.2014.894884 · Cited by 46
“The combined presence of a spontaneous type 1 ECG at baseline and a history of syncope identify subjects at risk of CA [46,48].”
BackgroundSelf-citation
Metadata
- Authors
- Priori, S. G., Gasparini, M., Napolitano, C., Della Bella, P., Ottonelli, A. G., Sassone, B., Giordano, U., Pappone, C., Mascioli, G., Rossetti, G., De Nardis, R., & Colombo, M.
- Affiliations
- University of Pavia (IT)
- IRCCS Humanitas Research Hospital (IT)
- NYU Langone Health (US)
- Ospedale Versilia (IT)
- Azienda USL di Bologna (IT)
- Maria Cecilia Hospital (IT)
- Humanitas Gavazzeni (IT)
- Azienda Sanitaria Ospedaliera S.Croce e Carle Cuneo (IT)
- Corresponding author
- Priori, Silvia G.
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2012-01
- Volume
- 59
- Issue
- 1
- Pages
- 37-45
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W140924846
- Cited by
- 581
- References
- 26
- Citations by year
- 2026: 13 · 2025: 14 · 2024: 26 · 2023: 25 · 2022: 26 · 2021: 44 · 2020: 43 · 2019: 44 · 2018: 44 · 2017: 68 · 2016: 60 · 2015: 45 · 2014: 31 · 2013: 66 · 2012: 30
- FWCI
- 28.05
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Archivio Istituzionale della Ricerca - Università Vita-Salute San Raffaele (submittedVersion)
- Institutional Research Information System University of Ferrara (University of Ferrara) (submittedVersion)
- Funders
- Medtronic
- Boston Scientific Corporation
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Keywords
- Brugada syndrome, risk stratification, programmed electrical stimulation, implantable cardioverter-defibrillator, sudden cardiac death, syncope, ventricular effective refractory period, QRS fragmentation, arrhythmic events
- MeSH terms
- Adolescent, Adult, Aged, Cause of Death, Electric Stimulation, Electrocardiography, Female, Humans, Male, Middle Aged, Registries, Severity of Illness Index, Ventricular Fibrillation, Cohort Studies, Incidence, Survival Rate, Confidence Intervals, Defibrillators, Implantable, Tachycardia, Ventricular, Age Distribution, Sex Distribution, Risk Assessment, Patient Selection, Statistics, Nonparametric, Kaplan-Meier Estimate, Brugada Syndrome, Young Adult
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