For Brugada syndrome, the implantable cardioverter-defibrillator (ICD) remains first-line for secondary prevention in patients who have had syncope or cardiac arrest, as it is the only therapy proven to prevent sudden death. The notable advance is in ablation: the randomized BRAVE trial showed that epicardial substrate ablation significantly reduced VF recurrence in symptomatic patients (hazard ratio 0.29), with the large majority remaining VF-free, and a 2025 Heart Rhythm Society consensus now recognizes substrate-guided epicardial ablation as a valuable strategy for high-risk or recurrent disease — as an adjunct or alternative to the ICD, especially in those with frequent events or who decline a device.
Pharmacologically, quinidine (which blocks the transient outward potassium current) suppresses arrhythmias and is used for recurrent VF, electrical storm, or frequent ICD shocks, while isoproterenol infusion is first-line for acute electrical storm. Equally important is avoiding drugs that unmask or worsen the phenotype (sodium channel blockers, certain psychotropics and anesthetics) and aggressively treating fever, which can precipitate arrhythmias.
Further reading: BRAVE epicardial ablation (Nademanee et al., Heart Rhythm 2025); 2025 epicardial VA ablation consensus statement; Brugada syndrome GeneReviews.