The document presents findings from a study involving 308 patients with Brugada syndrome, indicating that ventricular tachycardia/ventricular fibrillation inducibility via programmed electrical stimulation is not a reliable predictor of sudden death risk. It emphasizes that other factors, such as spontaneous type-1 ECG and QRS fragmentation, are significant risk indicators. The study suggests that programmed stimulation may not be useful for risk stratification in this population.

1. PRELUDE (Programmed Electrical
Stimulation Predictive Value in Brugada
Syndrome)

2. PRELUDE (Programmed Electrical Stimulation
Predictive Value in Brugada Syndrome)
C Napolitano (Fondazione Salvatore Maugeri, Pavia, Italy)
Heart Rhythm Society 2011 Scientific Sessions
• An analysis based on an Italian registry of 308 patients with Brugada syndrome
who underwent programmed electrical stimulation (PES) studies according to
one consistent protocol (unlike earlier multicenter studies that were based on
varying PES protocols)
• Background:
Brugada syndrome is a genetic disorder posing an elevated risk of syncope
and sudden death
Patients identified with the syndrome by ECG can be fitted with primary-
prevention ICDs
• Patient population:
Patients with no structural heart disease or history of cardiac arrest and either
a spontaneous or drug-therapy-induced type-1 ECG
PES: programmed electrical stimulation
ICD: implantable cardioverter-defibrillator

3. PRELUDE: Results
• VT/VF inducibility by PES is not a significant predictor of sudden death and
therefore can't effectively be used to risk-stratify such patients for treatment with
an ICD
Predictors of arrhythmic events in multivariate analysis, by prognostic
strength and HR (95% CI)—median 34-month follow-up
Predictor Sensitivity (%) Specificity (%) NNT HR (95% CI) p
VT/VF inducibility 35.7 58.8 102 1.03 (0.34–3.16) 0.96
VRP<200 vs ≥200 ms 78.6 62.9 13.2 3.9 (1.03–12.79) 0.04
Spontaneous type-1 ECG syncope 42.9 90.5 6.8 4.2 (1.38–12.79) 0.012
QRS-f 42.9 93.5 4.7 4.9 (1.54–15.8) 0.007
NNT: number needed to treat with an ICD to prevent one sudden death; VRP: ventricular refractory
period; QRS-f: QRS-interval fragmentation; VT/VF: ventricular tachycardia/ventricular fibrillation

4. PRELUDE: Commentary*
"We confirmed the prognostic value of a spontaneous 'type-1' electrocardiogram
and a history of syncope. . . . But for the first time in a large prospective cohort, we
[also] show that QRS fragmentation [QRS-f] and a ventricular refractory period
[VRP] <200 ms are independent risk indicators."
- Dr Carlo Napolitano
"[PRELUDE] provides strong, prospective evidence that programmed stimulation is
probably not going to be useful in this population."
- Dr Michael Gold
*All comments from PRELUDE: Inducibility in the EP lab a poor risk stratifier in Brugada syndrome
(http://www.theheart.org/article/1222633.do)

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