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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Brugada syndrome and inherited channelopathies

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

Unresponsive collapse requires immediate 999 activation, CPR and defibrillation according to Resuscitation Council UK ALS. In known or suspected Brugada syndrome, persistent high fever, arrhythmic syncope, nocturnal agonal breathing, sustained VT/VF or repeated ICD shocks requires urgent monitored hospital care and inherited-arrhythmia/critical-care input.

Synopsis

Recognise a diagnostic type 1 Brugada pattern and other inherited channelopathy clues, manage fever and malignant ventricular arrhythmia, and route patients and families to inherited-cardiac-condition expertise.

  • A type 1 Brugada ECG is coved ST elevation over 0.2 mV followed by T-wave inversion in at least one V1–V2 lead placed in the second, third or fourth intercostal space.
  • A spontaneous type 1 pattern is diagnostic in the right setting; fever- or sodium-channel-blocker-induced type 1 generally needs compatible clinical features for a Brugada syndrome diagnosis.
  • Type 2 saddleback appearances are not diagnostic alone and should not trigger an ICD without expert phenotyping.
  • Brugada events often occur at rest, during sleep or with fever; CPVT instead causes bidirectional or polymorphic ventricular arrhythmia during exercise or intense emotion with a usually normal resting ECG.
  • Treat fever promptly, maintain hydration and avoid Brugada-provocative drugs, cocaine and binge alcohol; persistent fever warrants ECG and monitored review.
  • An ICD is the definitive sudden-death protection for survivors of VT/VF arrest and selected high-risk symptomatic Brugada patients; most asymptomatic people do not need one.
  • Ajmaline or another sodium-channel challenge belongs in an experienced electrophysiology unit with high-right-precordial ECG and immediate resuscitation capability.
  • A negative genetic test does not exclude Brugada syndrome; first-degree relatives need clinical screening through an inherited cardiac conditions service.

Key red flags

Brugada clinical event

Unexplained syncope at rest, nocturnal agonal breathing, documented polymorphic VT/VF or cardiac arrest—especially during fever—raises immediate risk concern.

Investigation priorities

01
12-lead ECG with high V1–V2 positionsFirst step

Identify spontaneous type 1 Brugada morphology and measure PR, QRS and QTc.

Management branches

patternSuspected Brugada pattern

A right-precordial Brugada-like pattern or compatible syncope/family history is found.

  1. Check symptoms, family history, fever, medications/recreational drugs and reversible phenocopies; repeat correctly placed standard and high-right-precordial ECGs.
  2. If spontaneous type 1 or arrhythmic symptoms are present, obtain urgent electrophysiology/inherited-cardiac review and restrict driving according to specialist advice.
  3. If the ECG is non-diagnostic but suspicion persists, arrange specialist sodium-channel challenge; never give ajmaline as an unsupervised diagnostic trial.
  4. Risk-stratify using arrest/VT/VF, syncope mechanism and spontaneous versus induced pattern—not genetic result or family history alone—and discuss observation versus ICD.

Key medicines

Paracetamol1 g orally every 4 hours as required for fever, no more than four doses (4 g) in 24 hours; do not continue beyond 3 days without medical review.Do not combine with another paracetamol-containing product. Use a lower maximum or seek prescriber advice with low body weight, severe liver/renal impairment, malnutrition or hazardous alcohol use; persistent fever still needs urgent review.
Isoprenaline infusionBrugada electrical storm is a specialist off-label exception. A current UK SmPC infusion starts at 0.01 microgram/kg/min IV and allows 0.01 microgram/kg/min increments to 0.15 microgram/kg/min; the electrophysiology/critical-care team titrates to arrhythmia suppression under continuous ECG and BP monitoring.The UK SmPC is licensed for bradycardia/AV block and lists pre-existing ventricular arrhythmia as a contraindication; Brugada storm use therefore requires explicit expert guideline-based risk–benefit justification, not routine ward prescribing. It is not the RCUK standard tachyarrhythmia drug algorithm.
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Sources and review status8 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NHS Genomics Education: Brugada syndromeType 1 definition, genomic limits, family screening and fever/drug management.
  • NHS Genomics Education: CPVTExercise phenotype and specialist beta-blocker/flecainide/ICD pathway.
  • ESC: 2022 ventricular arrhythmias guidelineBrugada risk stratification, storm therapy and channelopathy management.
  • Resuscitation Council UK: Adult advanced life support 2025Immediate cardiac-arrest treatment and defibrillation.
  • eMC: Paracetamol 500 mg tablets SmPCExact adult antipyretic dose and maximum.
  • eMC: Isoprenaline infusion SmPCFormulation-specific IV dose range and the important licensed-indication/contraindication contrast with expert Brugada-storm use.
  • eMC: Propranolol 10 mg tablets SmPCLicensed arrhythmia dose range and contraindications; CPVT use remains specialist-led.
  • eMC: Flecainide acetate 50 mg tablets SmPCLicensed ventricular-arrhythmia dose boundary and ECG/renal safety context; CPVT use remains off-label and individualised.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom