Placed in cardiology recently and saw a patient / situation that I found interesting, details have been changed for confidentiality.
Young male diagnosed with Brugada Syndrome in their early teens presented to clinic for an assessment after referral. After exhausting other medications the referrer has requested a review to determine whether it would be safe to start him on another medication (stimulant class, but is not on the list of drugs to
preferably avoid for BrS). Patient reported no history of palpitations or light headedness since adolescence, and had never reported nor been admitted for any syncopal event.
I looked at his notes during & after the consultation and noted that they had previously undergone surgery to implant a loop recorder which was in for ~1 year post-diagnosis. Loop recorder documented no significant/relevant arrhythmia, even during self-reported event times and when the patient presented to ED with light headedness. In summary: they had no documented arrhythmia, no FH of SUDS, family was tested and had no Brugada-like ECG pattern, no episodes of syncope, and no genetic testing had been done. The only diagnostic criteria they met was the appearance of Type 1 ST segment elevation on Ajmaline challenge (no occurrence of VT, QRS prolongation or PVCs).
What would be your move here? I found it interesting that we wouldn't offer this gentleman an ICD due to him being 'low risk' and/or asymptomatic, but the consultant maintained that it was necessary to keep the diagnosis despite not meeting the criteria, and refused to approve the medication. I've unfortunately been unable to discuss the case further with the Dr as I’ve rotated and it’s summer now, but considering BrS is fairly novel and current testing methods have poor sensitivity/specificity I’d be interested in hearing your thoughts.
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