Appropriate and inappropriate therapies in remotely monitored patients with Brugada syndrome: what to expect?

We have recently read with great interest the article by Dyrbus et al. titled ‘Appropriate and inappropriate therapies in remotely monitored patients with cardiac implantable devices long-term experiences of a tertiary centre’. In their study, the authors presented long-term results of the remote monitoring (RM) of patients with an implantable cardioverter-defibrillator (ICD) from a large tertiary cardiovascular centre registry. In 1299 patients with ICDs (60.3% were patients with ischaemic cardiomyopathy, 39.3% with non-ischaemic cardiomyopathy and 24% implanted in secondary prevention) with a median follow-up duration of RM of 4.4 years, the percentage of patients with appropriate therapies for ventricular arrhythmias exceeded 25% and the prevalence of atrial fibrillation was 40.8%.¹

In our opinion, the attention in not generalizing the obtained data is crucial; for example, it is already known that Brugada syndrome (BrS) patients stratified as low arrhythmic risk profile have a low probability of major ventricular arrhythmic events. For these reasons, in our clinical practice, an accurate and multiparametric stratification of patients remains crucial and essential, and to date, ICD implantation is the only established effective therapy to protect against sudden cardiac death in high-risk patients.² Furthermore, patients affected by BrS differ from the majority of patients implanted with an ICD for a structural heart disease, and especially in this population, ICDs have been associated with high complication rates. From more recent literature data, S-ICD is considered a good option and the most advanced device in place for young patients with BrS but who possess specific implantation criteria, evaluated during an adequate and careful screening process by an experienced staff.³

Considering the importance that new data can bring to deepen our knowledge to better select BrS patients candidates for an ICD, the study published by the authors could offer interesting information if we could analyse the data regarding in particular this subgroup based on their implantation indication. Therefore, regarding BrS patients, if any data are available, what was the percentage of patients with appropriate therapies for ventricular arrhythmias, inappropriate therapies and atrial fibrillation? We largely agree that, thanks to the increased use of remote monitoring, further analyses are necessary to stratify the risk of ventricular arrhythmias in the contemporary practice, but with attention to the various specific subgroups of patients.