Quinidine therapy in patients with Brugada syndrome

Professor, Lariboisiere University Hospital, Paris, France
Antoine Leenhardt

The Brugada syndrome (BS) is an inherited arrhythmogenic disease associated with a risk of sudden cardiac death due to ventricular fibrillation. Due to the high rate of recurrences of the arrhythmic events, the treatment of patients rescued from sudden cardiac death or having experienced syncope is based on an implantable defibrillator (ICD). In asymptomatic patients detected by chance or after a family inquiry the therapeutic strategy and risk stratification are not clearly established. According to Brugada, risk stratification depends on the presence of 2 main markers: a spontaneous coved-type ECG pattern and VT/VF inducibility during electrophysiological study. The usefulness of other markers was not established. In absence of other recognized option, these results lead some authors to propose the prophylactic implantation of an ICD in asymptomatic inducible subjects with spontaneous coved-type BS-ECG. A recent international consensus report underlines the lack of conclusive evidence to guide risk-stratification in asymptomatic patients with BS. The management of asymptomatic BS remains a key-issue. The therapeutic options are either no treatment at all or an ICD implantation.
Belhassen and colleagues observed that class I antiarrhythmic agents which inhibit I_to (mainly quinidine) prevented arrhythmia induction as well as arrhythmia recurrences on a long term follow-up in 4 of 5 cardiac arrest survivors of BS. At the same time, quinidine efficacy was mentioned in isolated cases including in the setting of electrical storms of polymorphic ventricular tachycardia. As quinidine appeared a valuable drug in patients with a life-threatening arrhythmia, we assumed that it may also represent a pharmacological option in asymptomatic patients. We will report our first experience with quinidine in selected patients with BS.