Brugada syndrome: should we be screening patients before prescribing psychotropic medication?

Abstract

Brugada syndrome (BrS) presents with a characteristic electrocardiogram (ECG) and is associated with sudden cardiac death. Until now, prolongation of QTc interval and its association with Torsade de Pointe and possible fatal arrhythmia have been the focus of routine baseline ECGs before prescribing psychotropic medication. A semi-systematic literature review was conducted using PubMed. The terms ‘Brugada’, ‘Brugada Syndrome’ AND ‘psychotropic’ ‘antipsychotic’ ‘antidepressant’ ‘mood stabilisers’ ‘clozapine’ ‘Tricyclic Antidepressants’ ‘Lithium’ were searched. From a search that delivered over 200 articles, 82 articles were included. Those that included details around causative medication, doses of medication and where clear timeline on drug cause were included. Where clarification was needed, the manufacturer of the medication was contacted directly. Psychotropic medication can be associated with BrS, Brugada phenocopy or unmasking of BrS, in overdose or in normal doses. Our results include a table summarising a number of psychotropic overdoses that led to BrS unmasking. Routine screening for BrS in patients before prescribing psychotropic medication is a natural extension of the baseline ECG currently routinely done to rule out QTc prolongation. Psychiatrists need to invest in ensuring better skills in interpreting ECGs and work closer with cardiologists in interpreting ECGs.

Long-term follow-up of patients with Brugada syndrome: Foremost risk factors associated with overall arrhythmic events

“…Briefly, ≥2 mm (0.2 mV) dome-type ST segment/J point elevation in V1–V3 followed by a negative T wave was defined as “type 1 ST segment elevation.” A change in saddleback appearance with ≥2 mm ST elevation (with ≥1 mm ST elevation in the pit) followed by a positive or biphasic T wave was defined as “type 2 ST segment elevation.” Finally, “type 3 ST segment elevation” was defined as saddleback or dome-type < 1 mm ST segment elevation. [ 2 ] Type 1 ST segment elevation is referred to as “Brugada ECG,” while types 2 and 3 are not considered to be diagnostic. The diagnosis of BS was definitively established in the presence of type 1 ST segment elevation (Brugada ECG) in more than one right precordial lead (spontaneously or with the use of a sodium channel blocker) in the presence of at least one of the following: documented VF; polymorphic VT, family history of SCD under 45 years of age, type 1 ECG in family members; induction of VT with programmed electrical stimulation (PES); syncope; nocturnal agonal respiration.…”

“…Finally, "type 3 ST segment elevation" was defined as saddleback or dome-type < 1 mm ST segment elevation. [2] Type 1 ST segment elevation is referred to as "Brugada ECG," while types 2 and 3 are not considered to be diagnostic. The diagnosis of BS was definitively established in the presence of type 1 ST segment elevation (Brugada ECG) in more than one right precordial lead (spontaneously or with the use of a sodium channel blocker) in the presence of at least one of the following: documented VF; polymorphic VT, family history of SCD under 45 years of age, type 1 ECG in family members; induction of VT with programmed electrical stimulation (PES); syncope; nocturnal agonal respiration.…”

“…[ 1 ] It is estimated that BS is responsible for 20% of SCDs in the population without structural heart disease while it accounts for 4% to 12% of all SCDs. [ 2 ] Its prevalence is thought to be around 5/10,000 worldwide with the majority being males, but this figure may not reflect true prevalence due to varying electrocardiography (ECG) findings and the fact that most patients have the masked BS phenotype. Some patients may be completely asymptomatic throughout their life, while some develop SCD [ 3 , 4 ] which is most frequently encountered in the fifth decade of life.…”

Long-Term Follow-Up of Patients with Brugada Syndrome: Foremost Risk Factors Associated with Arrhythmic Events

“…BS is characterized by ST segment elevation in right precordial leads (V1-3), ventricular tachycardia (VT), ventricular fibrillation (VF) and sudden cardiac death (SCD) in individuals without structural heart disease [1]. It is estimated that BS is responsible for 20% of SCDs in the population without structural heart disease while it accounts for 4-12% of all SCDs [2]. Its prevalence is thought to be around 5/10,000 worldwide with the majority being males, but this figure may not reflect true prevalence due to varying electrocardiography (ECG) findings and the fact that most patients have the masked BS phenotype.…”

“…A change in saddleback appearance with ≥ 2 mm ST elevation (with ≥ 1 mm ST elevation in the pit) followed by a positive or biphasic T wave was defined as "Type 2 ST segment elevation". Finally, "Type 3 ST segment elevation" was defined as saddleback or dome-type < 1 mm ST segment elevation [2]. Type 1 ST segment elevation is referred to as "Brugada ECG", while Types 2 and 3 are not considered to be diagnostic.…”