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cardio.brugada-syndrome.chronic.v1PRODUCTION
cardio.brugada-syndrome.chronic.v1

Brugada syndrome (chronic ambulatory — SCD risk stratification)

cardiologychronicadult
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm BrS suspicion (type 1 ECG / arrhythmic syncope / family SCD); not benign RBBB/early repolarization

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Actions
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Advance rule
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Advance when

BrS clinically suspected

Patient inputs (10)

Risk profile; pediatric fever-triggered events

Fever unmasks/triggers BrS arrhythmia — antipyretic plan

Detect Na-blockers/psychotropics on brugadadrugs.org avoid-list

Spontaneous vs drug-induced type 1 (spontaneous = higher risk)

Arrhythmic (vs vasovagal) syncope is a major ICD risk factor

Aborted SCD / sustained VT = secondary-prevention ICD (Class I)

Quinidine dosing; comorbidity

SCN5A status — cascade + conduction-disease risk

Family SCD history + cascade screening

AF common in BrS; antiarrhythmic choice constrained (avoid class IC)

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Severity triggers (9)

9 need judgement
  • informationallife_threateningaborted_scd_secondary_prevention
    Aborted SCD / documented sustained VT/VF — secondary-prevention ICD Class I — 2017 AHA/ACC/HRS VA
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningicd_storm_quinidine_ablation
    Recurrent VF / ICD electrical storm — quinidine; refractory → epicardial RVOT substrate ablation — 2022 ESC VA
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverespontaneous_type1_plus_syncope
    Spontaneous type 1 ECG + arrhythmic (non-vasovagal) syncope — high risk; primary-prevention ICD — 2022 ESC VA
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefever_triggered_branch
    Febrile illness in BrS — fever unmasks type 1 + precipitates VF; aggressive antipyresis + low threshold for monitored setting (esp. pediatric) — 2022 ESC VA
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredrug_avoidance_branch
    Patient on a brugadadrugs.org agent (class IC/IA Na-blocker, select psychotropics, cocaine) — deprescribe/substitute; class IC contraindicated for AF in BrS — brugadadrugs.org
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_special_pop
    Pregnancy with BrS — ICD compatible, aggressive fever management, avoid brugadadrugs.org agents incl. some tocolytics/anesthetics; cardio-obstetric — ESC 2018 Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatescn5a_conduction_branch
    SCN5A-positive — conduction disease (PR/HV prolongation) + AF risk; cascade screening; pacing if symptomatic conduction disease (ICD-capable) — 2013 consensus
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateasymptomatic_spontaneous_intermediate
    Asymptomatic spontaneous type 1 — intermediate risk; shared-decision EP programmed stimulation (debated), close surveillance, fever/drug-avoidance — Shanghai/Sieira
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_special_pop
    CKD — quinidine renal dose-gating — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Brugada syndrome SCD-protection (2013 HRS/EHRA/APHRS; 2017 AHA/ACC/HRS VA; 2022 ESC VA)
axis: brugada_scd_protectionstep 1 - Step 1 — Universal measures (all BrS): fever plan + drug-avoidance + cascade
Selected step "Step 1 — Universal measures (all BrS): fever plan + drug-avoidance + cascade" — Any confirmed BrS or pathogenic-variant carrier
  • acetaminophen
    first line
    antipyretic
    650–1000 mg • PO • q6h PRN fever
    triggers: febrile_illness_in_BrS
    Aggressive prompt antipyresis — fever unmasks/triggers Brugada VF; patient-held fever action plan (2022 ESC VA)
    rxcui 161
  • avoid brugadadrugs.org agents (class IC/IA Na-blockers, select psychotropics, cocaine, excess alcohol)
    first line
    deprescribe
    triggers: BrS_confirmed
    Na-channel-blocking and other listed drugs precipitate type 1 pattern + VF — lifelong avoidance (brugadadrugs.org; 2013 consensus)

outpatient playbook — drug actions (3)

  1. 1. fever action plan (acetaminophen)
    650–1000 mg q6h PRN • PO • PRN fever
    trigger: Any BrS (2022 ESC VA)
    Fever unmasks VF — prompt antipyresis
  2. 2. ICD if high risk
    device • device • n/a
    trigger: Aborted SCD / spontaneous type 1 + arrhythmic syncope (2017 AHA/ACC/HRS VA)
    Only SCD-protective therapy
  3. 3. quinidine for VF burden / ICD declined
    600–900 mg/day divided • PO • BID–TID
    trigger: Recurrent VF / ICD storm / ICD declined (Belhassen)
    Reduces VF recurrence + ICD shocks

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Type 1 Brugada ECG (coved ST ≥2 mm V1–V2), spontaneous or provoked; Unexplained syncope (often nocturnal / at rest); Aborted SCD / family history of SCD or Brugada.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Brugada syndrome (chronic ambulatory — SCD risk stratification)** (cardio.brugada-syndrome.chronic.v1).
Phenotype framing: BrS vs Brugada phenocopy (ischemia/electrolyte/drug) vs RBBB vs ARVC vs early repolarization
Scope: Confirm BrS suspicion (type 1 ECG / arrhythmic syncope / family SCD); not benign RBBB/early repolarization

No severity triggers fired against current inputs.

Plan

Regimen axis: **Brugada syndrome SCD-protection (2013 HRS/EHRA/APHRS; 2017 AHA/ACC/HRS VA; 2022 ESC VA)** — step "Step 1 — Universal measures (all BrS): fever plan + drug-avoidance + cascade".
1. acetaminophen 650–1000 mg PO q6h PRN fever (antipyretic, first line) — Aggressive prompt antipyresis — fever unmasks/triggers Brugada VF; patient-held fever action plan (2022 ESC VA)
2. avoid brugadadrugs.org agents (class IC/IA Na-blockers, select psychotropics, cocaine, excess alcohol) (deprescribe, first line) — Na-channel-blocking and other listed drugs precipitate type 1 pattern + VF — lifelong avoidance (brugadadrugs.org; 2013 consensus)

Setting playbook (outpatient) — Risk-stratify, ICD high-risk, quinidine/ablation for VF burden, lifelong fever + drug-avoidance, cascade (2017 AHA/ACC/HRS VA; 2022 ESC VA)
3. fever action plan (acetaminophen) 650–1000 mg q6h PRN PO PRN fever — Any BrS (2022 ESC VA) (Fever unmasks VF — prompt antipyresis)
4. ICD if high risk device device n/a — Aborted SCD / spontaneous type 1 + arrhythmic syncope (2017 AHA/ACC/HRS VA) (Only SCD-protective therapy)
5. quinidine for VF burden / ICD declined 600–900 mg/day divided PO BID–TID — Recurrent VF / ICD storm / ICD declined (Belhassen) (Reduces VF recurrence + ICD shocks)

Non-pharmacologic actions:
- Inherited-arrhythmia centre + EP referral — 2013 consensus
- Genetic counseling + first-degree family cascade screening — 2013 consensus
- Lifelong brugadadrugs.org avoidance + fever education — brugadadrugs.org
- Epicardial RVOT ablation for refractory storm — 2022 ESC VA

AVOID / contraindication checks:
- Avoid brugadadrugs.org agents class IC IA Na blockers select psychotropics cocaine — brugadadrugs.org; 2013 consensus
- Aggressive prompt antipyresis fever unmasks Brugada VF — 2022 ESC VA
- ICD is the only SCD protective therapy quinidine ablation are adjuncts — 2017 AHA/ACC/HRS VA
- Class IC antiarrhythmics contraindicated for AF in BrS — 2013 consensus

Monitoring

Regimen monitoring:
- ICD interrogation per schedule — 2017 AHA/ACC/HRS VA
- quinidine QT and GI tolerance if used — 2013 consensus
- fever action plan adherence reviewed each visit — 2022 ESC VA
- medication reconciliation against brugadadrugs.org — brugadadrugs.org
- family cascade screening and serial evaluation — 2013 consensus

Setting (outpatient) monitoring:
- ICD interrogation; quinidine QT/GI if used — 2017 AHA/ACC/HRS VA
- Fever-plan + drug-avoidance adherence each visit — 2022 ESC VA

Follow-up plan: First-degree family cascade screening; lifelong drug-avoidance + fever education
- Close-out criterion: cascade + long-term plan documented

Monitoring phase: ICD interrogation; symptom + fever-plan adherence; reassess if new syncope

Disposition

Current setting: outpatient — Risk-stratify, ICD high-risk, quinidine/ablation for VF burden, lifelong fever + drug-avoidance, cascade (2017 AHA/ACC/HRS VA; 2022 ESC VA)

Disposition criteria:
- High risk → ICD + fever/drug-avoidance + cascade
- Intermediate (asymptomatic spontaneous type 1) → risk-stratify (EP debated), close follow-up
- Low risk (drug-induced asymptomatic) → reassurance + fever/drug-avoidance + cascade

Escalation triggers (move to higher acuity):
- VF / electrical storm → ED + acute Brugada-storm pathway — 2022 ESC VA
- New arrhythmic syncope → re-stratify, expedite ICD — 2017 AHA/ACC/HRS VA
- Recurrent ICD shocks → quinidine then ablation — 2022 ESC VA

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Aborted SCD / documented sustained VT/VF — secondary-prevention ICD Class I — 2017 AHA/ACC/HRS VA
- [LIFE_THREATENING] Recurrent VF / ICD electrical storm — quinidine; refractory → epicardial RVOT substrate ablation — 2022 ESC VA
- [SEVERE] Spontaneous type 1 ECG + arrhythmic (non-vasovagal) syncope — high risk; primary-prevention ICD — 2022 ESC VA

Citations

- 2013 HRS/EHRA/APHRS Inherited Arrhythmia Expert Consensus + 2017 AHA/ACC/HRS VA Guideline + 2022 ESC Ventricular Arrhythmia Guideline [PMID:23994779](https://pubmed.ncbi.nlm.nih.gov/23994779/)
- Cited evidence (PMID 29084731) [PMID:29084731](https://pubmed.ncbi.nlm.nih.gov/29084731/)
- Cited evidence (PMID 36017572) [PMID:36017572](https://pubmed.ncbi.nlm.nih.gov/36017572/)

Last reconciled with current guidelines: 2026-05-16.
References
  • 2013 HRS/EHRA/APHRS Inherited Arrhythmia Expert Consensus + 2017 AHA/ACC/HRS VA Guideline + 2022 ESC Ventricular Arrhythmia Guideline — PMID:23994779
  • Cited evidence (PMID 29084731) — PMID:29084731
  • Cited evidence (PMID 36017572) — PMID:36017572