How can I differentiate between Brugada Syndrome and other causes of syncope in my patients?

To differentiate Brugada Syndrome from other causes of syncope, a detailed clinical and family history is essential, focusing on syncope characteristics, family history of sudden cardiac death under 40 years, and any history of arrhythmic events or structural heart disease ¹,². Brugada Syndrome typically presents with syncope due to ventricular arrhythmias, often occurring at rest or during sleep, and may be associated with a family history of sudden cardiac death or known inherited cardiac conditions ¹,².

Perform a 12-lead ECG to identify the characteristic Brugada pattern—coved-type ST-segment elevation in the right precordial leads (V1-V3)—which is diagnostic ¹. This ECG pattern distinguishes Brugada Syndrome from other syncope causes such as vasovagal syncope, postural hypotension, or epilepsy, which do not show this specific ECG abnormality ¹,².

In contrast, vasovagal syncope often has identifiable triggers (e.g., prolonged standing, pain) and prodromal symptoms like sweating or warmth, and situational syncope is provoked by specific actions such as coughing or micturition ¹,². Epileptic seizures have features such as tongue biting, postictal confusion, and witnessed abnormal movements, which are absent in Brugada Syndrome ².

For patients with suspected cardiac arrhythmic syncope, including Brugada Syndrome, ambulatory ECG monitoring (Holter or implantable loop recorder) is recommended to detect arrhythmias, as Brugada Syndrome can cause polymorphic ventricular tachyarrhythmias without structural heart disease ¹,²[(Viskin and Belhassen, 1998)].

Referral to cardiology for specialist assessment including echocardiography and possibly electrophysiological studies is indicated if Brugada Syndrome is suspected, especially if the ECG is suggestive or there is a family history of sudden cardiac death ¹,². Genetic testing may also be considered as Brugada Syndrome is an inherited channelopathy related to sodium channel mutations, which can overlap with other inherited arrhythmia syndromes such as Long QT syndrome [(Cerrone et al., 2001)].

In summary, differentiation relies on clinical history, characteristic ECG findings, exclusion of other causes by history and examination, and specialist cardiac investigations including ambulatory ECG and possibly genetic testing ¹,²[(Viskin and Belhassen, 1998); (Cerrone et al., 2001)].