Brugada syndrome (BS) and syncope: a complex therapeutic issue

Abstract

A 66 year-old man was brought to the emergency room (ER) for syncope and sphincter incontinence; syncope duration was about 15 min. Similar short duration episodes had been referred by his relatives during the last months, following small traumas; no seizures had been registered. Patient told he was affected with BS, having already been diagnosed 5 years before, after performing an electrocardiogram (ECG) highly suggestive for it. He had performed an electrophysiologic study, which had not shown any sustained ventricular arrhythmias after scheduled stimulation. This finding together to the lack of symptoms had suggested a conservative treatment, notwithstanding that familiar history documented his father's sudden death. Patient was also affected with hypertension and gastroesophageal reflux disease. Clinical examination did not suggest any significant findings. Laboratory tests, supra aortic Doppler ultrasound, electroencephalogram (EEG) and brain CT were normal. ECG showed sinus rhythm with a heart frequency of 82 bpm, QRS axis was normal, as well as atrioventricular conduction. ST coved-type elevation with right bundle branch block pattern and repolarization abnormalities were found. Holter ECG and Doppler echocardiography were also performed. The onset of syncope in presence of BS suggested the evaluation of this case report together with electrophysiolgists and neurologists. Therefore, an implantable cardioverter defibrillator (ICD) was implanted through left subclavian vein. He was discharged eight days after hospitalization, diagnosis was "Syncope in patient affected with BS, hypertension". Arrhythmogenic risk stratification is necessary; the indication for implanting this device is obvious in symptomatic patients, whereas it is controversial in patients presenting only ECG patterns of BS. In conclusion, the above mentioned case report rises remarkable diagnostic and therapeutic issues. The finding of BS in a patient with syncope indicates the opportunity of implanting a defibrillator and only clinical experience and common opinions may help doctors in taking the most appropriated, often difficult, decisions.