From the Guidelines
Asymptomatic patients with early repolarization on a 12-lead ECG should be observed without treatment, as recommended by the 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1.
Key Considerations
- Early repolarization is a common electrocardiographic finding characterized by J-point elevation, concave upward ST-segment elevation, and prominent T waves in two or more contiguous leads.
- This pattern is typically seen in the precordial leads V2-V5 or the inferior leads II, III, and aVF.
- Early repolarization is generally considered a benign, normal variant found in 1-13% of the general population, particularly in young, athletic males, and individuals of African descent.
Recommendations
- Observation without treatment is recommended for asymptomatic patients with early repolarization pattern on ECG 1.
- An ICD is recommended for patients with early repolarization pattern on ECG and cardiac arrest or sustained VA, if meaningful survival greater than 1 year is expected 1.
- Genetic testing is not recommended for patients with early repolarization pattern on ECG 1.
Important Differentiating Features
- Absence of reciprocal ST depression
- Lack of Q waves
- Characteristic concave upward ("smiley face") ST elevation rather than the convex or horizontal ST elevation seen in ischemia
Further Evaluation
- If a patient with early repolarization presents with concerning symptoms like chest pain, syncope, or palpitations, further cardiac evaluation is warranted to rule out underlying pathology.
- The 2016 scientific statement from the American Heart Association provides a comprehensive review of the literature on early repolarization, but the 2017 AHA/ACC/HRS guideline provides the most up-to-date recommendations for management 1.
From the Research
Early Repolarization on a 12-Lead ECG
- Early repolarization (ER) pattern on a 12-lead ECG has been associated with an increased risk of sudden cardiac death (SCD) and ventricular fibrillation 2.
- The prevalence of ER pattern ≥0.1 mV was more common in victims of SCD (14.4%) than in survivors of an acute coronary event (7.9%) 2.
- ER pattern is characterized by an elevation of the QRS-ST junction in at least 2 inferior or lateral leads, manifested as QRS notching or slurring 2.
Risk Factors and Associations
- The presence of ER increases the vulnerability to fatal arrhythmia during acute myocardial ischemia 2.
- Patients with ER pattern and syncope have a higher risk of life-threatening ventricular arrhythmias (VAs) 3.
- The 5-year incidence of VAs and arrhythmic events presumably responsible for syncope was 4.9% and 11.0%, respectively, in patients with ER pattern and syncope 3.
- ER pattern is associated with an elevated risk of unexpected death and a decreased risk of cardiac and all-cause death 4.
Clinical Implications
- Device implantation based on detailed history taking seems to be a reasonable strategy for patients with ER pattern and syncope 3.
- Implantable cardioverter-defibrillator implantation and isoproterenol are suggested therapies for patients with early repolarization syndrome (ERS) 5.
- Risk stratification in asymptomatic patients with ER pattern still remains a grey area 5.
- Specific ER pattern morphologies and location are associated with an adverse prognosis 4.