https://orcid.org/0000-0002-0528-0852
Abstract
The diagnosis of Brugada syndrome (BrS) requires the presence of a coved (Type 1) ST segment elevation in the right precordial leads of the electrocardiogram (ECG). The dynamic nature of the ECG is well known, and in patients with suspected BrS but non-diagnostic ECG at baseline, a sodium channel blocker test (SCBT) is routinely used to unmask BrS. There is little doubt, however, that in asymptomatic patients, a drug-induced Brugada pattern is associated with a much better prognosis compared to a spontaneous Type 1 ECG. The SCBT is also increasingly used to delineate the arrhythmogenic substrate during ablation studies. In the absence of a “gold standard” for the diagnosis of BrS, sensitivity and specificity of the SCBT remain elusive. By studying patient groups with different underlying diseases, it has become clear that the specificity of the test may not be optimal. This review aims to discuss the pitfalls of the SCBT and provides some directions in whom and when to perform the test. It is concluded that because of the debated specificity and the overall very low risk for future events in asymptomatic individuals, patients should be properly selected and counseled before SCBT is performed and that SCBT should not be performed in asymptomatic patients with a Type 2 Brugada pattern and no family history of BrS or sudden death.
Use, misuse, and pitfalls of the drug challenge test in the diagnosis of the Brugada syndrome. *Diagnosis of Brugada syndrome is based on the modified Shanghai criteria (see Table 2). **Indications to perform SCBT depend on symptoms, family history, and baseline ECG. Before performing the test, patients should be informed about test specificity, risk of complications, and generally excellent prognosis if asymptomatic. All-comers: asymptomatic patients and patients with symptoms including ventricular fibrillation/aborted cardiac arrest. Lethal arrhythmic events: sudden cardiac death, ventricular fibrillation or sustained ventricular tachycardia, and appropriate implantable cardioverter-defibrillator interventions (i.e. shocks or antitachycardia pacing delivered for ventricular tachycardia/fibrillation). ECG, electrocardiogram; RVOT, right ventricular outflow tract; SCBT, sodium channel blocker test.
