Brugada atrial rhythm treatment strategy: explorative analysis from barts study

Introduction Atrial fibrillation (AF) is over-represented in Brugada syndrome (BrS), often at younger age and without structural risk factors, suggesting a shared, channel-based substrate with ventricular arrhythmias (VA). Class Ic agents are contraindicated, while alternatives such as hydroquinidine (Class Ia) or amiodarone (Class III) carry non-neglectable side effect; catheter ablation (CA) is appealing but evidence is limited. Purpose To describe real-world AF management in BrS, compare freedom from AF recurrence across strategies, and explore clinical determinants of AF incidence, recurrence, and strategy selection. Method Multicentre, retrospective cohort of consecutive BrS patients (2010 onwards) from 2 Italian centres, ESC criteria adjudicated, with ≥12-month follow-up. Initial strategies were watchful waiting (WW), antiarrhythmic drugs (AADs), or CA. Kaplan–Meier compared time to first AF recurrence. Exploratory Cox models probed recurrence predictors. Multinomial and binary model (rhythm-control vs non–rhythm-control) assessed determinants of strategy choice. Results Of 311 BrS patients (52% male; 47±13 years), 45 (14%) had AF (69% male; AF onset 50±16 years). In AF group, spontaneous type-1 pattern was less frequent, while drug induced type-1 after Class Ic exposure predominated, and VA inducibility at electrophysiology study (EPS) was higher. First-line management: WW 20/45 (44%), AADs 15/45 (33%), CA 4/45 (9%); 6/45 (13%) undocumented. Baseline features were similar across groups (table 1). Over a median 20 [12–80] months, first recurrences occurred in 14/20 (70%) WW, 11/15 (73%) AADs (mostly β-blockers), and 1/4 (25%) with CA. CA used cryoballoon in 1 and pulsed-field/radiofrequency in 3; the single recurrence followed cryo and was successfully re-ablated. Kaplan–Meier showed no significant difference across WW vs AADs vs CA (p=0.857, figure 1). By treatment intent, recurrences were 7/14 (50%) with non–rhythm-control vs 8/24 (33%) with rhythm-control (p=0.576). Cox models identified no independent predictors of recurrence (age at BrS diagnosis, spontaneous type-1 pattern, SCD family history, genetic, syncope, VA inducibility, initial strategy). Multinomial modelling of initial strategy showed borderline global association (p=0.051) with signals for age at AF diagnosis and CHA2DS2-VA (both p=0.02). In the binary model, symptoms (OR 22.90 [0.72-729.18]; p=0.076) and higher episode frequency (OR 13.91 [0.15-1333]; p=0.258) tended to favour rhythm-control. Conclusions In contemporary practice, BrS-associated AF is typically paroxysmal and managed conservatively at first presentation; in this cohort, conservative care did not yield higher recurrence than pharmacological rhythm-control or CA. No robust clinical predictors of recurrence emerged. Because pharmacological choices are limited, CA remains a reasonable option, but its incremental benefit over conservative strategies requires larger, prospective, treatment-directed studies.