Syncope in Brugada syndrome: Prevalence, clinical significance, and clues from history taking to distinguish arrhythmic from nonarrhythmic causes

BackgroundSyncope in Brugada syndrome (BrS) patients is a sign of increased risk for sudden cardiac death and usually is ascribed to cardiac arrhythmias. However, syncope often occurs in the general population, mostly from nonarrhythmic causes (eg, reflex syncope).ObjectiveThe purpose of this study was to distinguish arrhythmic events from nonarrhythmic syncope in BrS and to establish the clinical relevance of nonarrhythmic syncope.MethodsWe reviewed the patient records of 342 consecutively included BrS patients and conducted systematic interviews in 141 patients with aborted cardiac arrest (ACA) or syncope.ResultsIn total, 23 patients (7%) experienced ECG-documented ACA and 118 (34%) syncope; of these 118, 67 (57%) were diagnosed with suspected nonarrhythmic syncope. Compared to suspected nonarrhythmic syncope patients, ACA patients were older at first event (45 vs 20 years), were more likely to be male (relative risk 2.1) and to have urinary incontinence (relative risk 4.6), and were less likely to report prodromes. ACA was never triggered by hot/crowded surroundings, pain or other emotional stress, seeing blood, or prolonged standing. During follow-up (median 54 months), ACA rate was 8.7% per year among ACA patients and 0% per year among suspected nonarrhythmic syncope patients.ConclusionSyncope, especially nonarrhythmic syncope, often occurs in BrS. The high incidence of nonarrhythmic syncope must be taken into account during risk stratification. Arrhythmic events and nonarrhythmic syncope may be distinguished by clinical characteristics (absence of prodromes and, particularly, specific triggers), demonstrating the importance of systematic history taking.