Automatized quantitative electrocardiography from digitized paper electrocardiograms: A new avenue for risk stratification in patients with Brugada syndrome

[Display omitted] •We digitized the electrocardiograms (ECGs) of patients with Brugada syndrome.•We performed multi-parametric ECG quantification to assess risk in such patients.•We identified new ECG parameters independently associated with major events. Arrhythmic risk stratification is a major challenge in Brugada syndrome. Studies have evaluated risk stratification based on manually measured electrocardiogram (ECG) parameters at baseline and/or after drug challenge. To assess the predictive value of multiple ECG parameters measured automatically from digitized paper ECGs. During a prospective, multicentre cohort study that included patients with Brugada syndrome with type 1 ECG (spontaneously or drug-induced), paper ECGs were digitized and analysed. Major events were sudden cardiac death, aborted cardiac arrest and appropriate implantable cardioverter-defibrillator (ICD) therapy in the ventricular fibrillation (VF) zone. The predictive value of clinical and ECG parameters was assessed using univariable and multivariable Cox models. ECGs from 301 patients (74% male, mean age 43.1±13.3years, mean follow-up 7.1±5.6years) were analysed. Major events occurred in 6% of patients before diagnosis and 8% during follow-up. Two baseline ECG parameters were independently associated with major events: QRS prolongation in lead V1>113ms (hazard ratio [HR] 3.49, 95% confidence interval [CI] 1.72–7.09; P33.5ms (HR 3.56, 95% CI 1.52–8.31; P