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Lone Atrial Fibrillation and Brugada Syndrome
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Lone Atrial Fibrillation and Brugada Syndrome

I am a 29 year old male.  In May (when I was 28) I experienced an episode of atrial fibrillation (later diagnosed as lone afib).  Before medication my afib stopped naturally.   Since the episode I have had an ECGs which was normal.  

During the 2-3 years previous to the episode of afib I had a number of skipped beats which I had probably 5-6 ECGs for, 2 holter monitors, 1 event monitor, an ECG stress test and an echocardiogram.  All of which came back normal.

I've recently been reading about Brugada syndrome in people with Lone Atrial Fibrillation and it is really scaring me.  Most of my worry comes from this study: http://eurheartj.oxfordjournals.org/content/30/24/2985.full.pdf

11 out of 190 lone afib patients had ECGs typical of Brugada and all after pharmacological testing converted to the type 1 pattern.  According to the study, only one of the patients had a family history of SCD and none showed previous ECG abnormalities (although 20% of the non ICD group and 80% of the ICD group showed abnormalities after the afib).  

I have also read that patients with Brugada and Afib have far more episodes of sudden death.  All of this has got me really worried since I did not have any pharmacological testing and therefore am worried that all of my previous ECG's, holters, event monitors, stress test missed a concealed form of Brugada.  

My cardiologist (Atrial Fibrillation specialist Dr. Charles Kerr) didn't mention Brugada during my appointment.  Unfortunately, I have now moved to Spain and cannot go back to see him for another appointment.  

My questions are:

1) With all of the previous tests I had what is the likelihood Brugada could be concealed in all of them?  Is concealed Brugada ALWAYS concealed?  

2) Are there any other signs my cardiologists would look for that would have indicated Brugada?  I'm hoping the fact it was not mentioned means it was ruled out.  I have no family history of SCD.  

Thanks.

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Dear DubDeez,

Thank you for your query.

As I understand, you are a 29 year old male with only one documented episode of paroxysmal AF that subsided spontaneously without any specific treatment. There have been no recurrences and you have not lost your consciousness at any point of time. Also, there is no family history of sudden death. An arrhythmia expert has evaluated you and not found any abnormality in your baseline ECG (or in the numerous ECGs that have been taken subsequently).

Brugada syndrome is a highly variable disease characterized by a typical ECG finding of a particular type of ST elevation in certain leads with RBBB pattern in the absence of any other structural or coronary artery disease. This finding may be present as such or may be induced by certain drugs. The importance of this syndrome is the high incidence of potentially dangerous arrhythmias and sudden death. The paper that you are referring to was published from a well-known centre in Italy. If you go through the article carefully, you will find that they have screened 1523 patients with new-onset AF, of which only 190 had true lone AF. Their criteria for satisfying the diagnosis of lone AF were strict, and it is possible that in your case, such strict criteria may not have been followed. In any case, only 11/190 turned out to have Brugada. That is only about 6% of lone AF, and 0.07% of the total screened for new onset AF. In other words, > 99% of new onset AF and 94% of lone AF did not have Brugada syndrome.

Also, this is the first study to show such a relationship. We await further confirmation of such a presentation from other centres across the world.

A concealed Brugada on the ECG can only be diagnosed after pharmacological testing. The risks of concealed Brugada syndrome in the absence of any symptoms and no inducible arrhythmia remain very low. They do not need any defibrillator implantation, as per the current guidelines.  A history of transient loss of consciousness (syncope) is important. Otherwise, there are usually no specific symptoms or signs of Brugada other than identifying the ECG abnormality.

As of now, only those with syncope, those with ventricular arrhythmias (not AF), those resuscitated from cardiac arrest and those with family history of SCD/Brugada syndrome are routinely screened for the presence of a concealed Brugada syndrome. The pharmacological testing should be done by arrhythmia specialists/cardiac electrophysiologists in hospitals with suitable facilities for electrophysiological testing and treatment. If you want to rule out a concealed Brugada, you will have to undergo pharmacological testing.

Hope that this information helps and hope that you will get better soon.

Thank you for using MedHelp's "Ask an Expert" Service, where we feature some of world's renowned medical experts in their fields. Millions have benefitted from our service to get personalized advice for them and for their loved ones.

Best Regards,
Dr. Raja Sekhar Varma
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