A New Electrocardiographic Marker of Sudden Death in Brugada Syndrome: The S-Wave in Lead I

J Am Coll Cardiol. 2016 Mar 29;67(12):1427-1440. doi: 10.1016/j.jacc.2016.01.024.

Abstract

Background: Risk stratification in asymptomatic patients remains by far the most important yet unresolved clinical problem in the Brugada syndrome (BrS).

Objectives: This study sought to analyze the usefulness of electrocardiographic parameters as markers of sudden cardiac death (SCD) in BrS.

Methods: This study analyzed data from 347 consecutive patients (78.4% male; mean age 45 ± 13.1 years) with spontaneous type 1 BrS by ECG parameters but with no history of cardiac arrest (including 91.1% asymptomatic at presentation, 5.2% with a history of atrial fibrillation [AF], and 4% with a history of arrhythmic syncope). Electrocardiographic characteristics at the first clinic visit were analyzed to predict ventricular fibrillation (VF)/SCD during follow-up.

Results: During the follow-up (48 ± 38 months), 276 (79.5%) patients remained asymptomatic, 39 (11.2%) developed syncope, and 32 (9.2%) developed VF/SCD. Patients who developed VF/SCD had a lower prevalence of SCN5A gene mutations (p = 0.009) and a higher prevalence of positive electrophysiological study results (p < 0.0001), a family history of SCD (p = 0.03), and AF (p < 0.0001). The most powerful marker for VF/SCD was a significant S-wave (≥0.1 mV and/or ≥40 ms) in lead I. In the multivariate analysis, the duration of S-wave in lead I ≥40 ms (hazard ratio: 39.1) and AF (hazard ratio: 3.7) were independent predictors of VF/SCD during follow-up. Electroanatomic mapping in 12 patients showed an endocardial activation time significantly longer in patients with an S-wave in lead I, mostly because of a significant delay in the anterolateral right ventricular outflow tract.

Conclusions: The presence of a wide and/or large S-wave in lead I was a powerful predictor of life-threatening ventricular arrhythmias in patients with BrS and no history of cardiac arrest at presentation. However, the prognostic value of a significant S-wave in lead I should be confirmed by larger studies and by an independent confirmation cohort of healthy subjects.

Keywords: arrhythmia; electrocardiography; prognosis.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial

MeSH terms

  • Brugada Syndrome / complications
  • Brugada Syndrome / diagnosis*
  • Brugada Syndrome / physiopathology
  • Death, Sudden, Cardiac / epidemiology
  • Death, Sudden, Cardiac / etiology*
  • Electrocardiography*
  • Female
  • Follow-Up Studies
  • Humans
  • Italy / epidemiology
  • Male
  • Middle Aged
  • Prevalence
  • Prognosis
  • Prospective Studies
  • Risk Assessment / methods*
  • Survival Rate / trends
  • Time Factors