Overall, we feel that the evidence that we provided in 2002 and confirmed with the PRELUDE study—that a spontaneous type 1 pattern and a history of syncopal episodes (excluding syncopal episodes that are likely to be neurally mediated) is the strongest predictor of arrhythmic risk in Brugada syndrome and that the absence of a spontaneous type 1 pattern is the strongest predictor of favorable outcome at follow-up—is now further strengthened by these new data from Casado-Arroyo et al. that question the role of PES. In this respect, in light of the confirmed less malignant outcome of patients with Brugada syndrome, we believe PES inducibility may have an additional predictive value in addition to spontaneous type 1 pattern and syncope that may be highlighted only in a very large cohort that is able to demonstrate its effect. However, the lack of negative predictive value remains the major limitation in the clinical use of PES.
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