Exercise and Exercise Stress Testing in Brugada Syndrome: Diagnostic, Prognostic, and Safety Implications

Brugada syndrome is a cardiac channelopathy associated with sudden cardiac death caused by ventricular arrhythmias. Although pharmacologic Na⁺ channel blocker testing remains central to diagnosis, the role of exercise stress testing (EST) in Brugada syndrome is increasingly recognized. Evidence indicates that peak exercise may unmask rate-dependent depolarization abnormalities capable of provoking arrhythmias, whereas the early recovery phase-marked by abrupt sympathetic withdrawal and parasympathetic rebound-more commonly reveals repolarization abnormalities, unmasking the type-1 Brugada pattern and triggering ventricular arrhythmias. Exercise-induced premature ventricular contractions and ST-segment changes during early recovery may serve as clinically meaningful markers of arrhythmic risk. Despite rare case reports of exercise-triggered ventricular arrhythmias, EST appears generally safe when performed with appropriate monitoring and may enhance diagnostic accuracy, particularly when paired with high precordial lead placement or drug provocation. Optimizing EST protocols and integrating recovery-phase markers may improve individualized risk stratification in Brugada syndrome.