What is the diagnosis for a 70-year-old patient presenting with chest pain and electrocardiogram (ECG) findings of early repolarization?

From the Guidelines

For a 70-year-old patient with chest pain showing early repolarization on ECG, urgent cardiac evaluation is recommended as this finding requires careful differentiation from acute coronary syndrome. While early repolarization is often benign in younger patients, in a 70-year-old with active chest pain, it should be considered suspicious until proven otherwise 1. The patient should receive aspirin 325mg immediately if not contraindicated, and be transported to an emergency department for serial cardiac biomarkers (troponin), additional ECG monitoring, and possible cardiac consultation. Oxygen should be provided if saturation is below 94%. Pain management with nitroglycerin 0.4mg sublingual may be appropriate if systolic blood pressure exceeds 90mmHg.

Early repolarization typically presents with ST-segment elevation with upward concavity, prominent T waves, and notching of the J point, but these findings can mimic acute myocardial infarction, especially in elderly patients with risk factors 1. The combination of advanced age and active chest pain significantly increases the likelihood that these ECG changes represent true cardiac pathology rather than a benign variant, necessitating a thorough cardiac workup. According to the 2020 ESC guidelines for the management of acute coronary syndromes, patients with acute chest discomfort but no persistent ST-segment elevation should be differentiated from those with ST-segment elevation ACS, and their treatment should be tailored accordingly 1.

Key considerations in the diagnosis and management of this patient include:

• Urgent cardiac evaluation to rule out acute coronary syndrome
• Administration of aspirin and oxygen as indicated
• Serial cardiac biomarkers and ECG monitoring
• Possible cardiac consultation for further evaluation and management
• Pain management with nitroglycerin if systolic blood pressure exceeds 90mmHg. Given the potential for early repolarization to mimic acute myocardial infarction, especially in elderly patients, a thorough cardiac workup is essential to determine the underlying cause of the patient's symptoms 1.

From the Research

Diagnosis of Chest Pain with Early Repolarization

The diagnosis of a 70-year-old patient presenting with chest pain and electrocardiogram (ECG) findings of early repolarization can be challenging.

• The patient's symptoms and ECG findings must be carefully evaluated to determine the underlying cause of the chest pain.
• According to 2, early repolarization is a benign ECG phenomenon that can mimic acute myocardial injury or pericarditis, but it does not preclude the diagnosis of exercise-induced myocardial ischemia.
• The presence of S-T elevation in a patient with chest pain of possible cardiac origin mandates hospitalization and cardiac monitoring, even if the ECG confirms to a classic pattern of early repolarization 2.

Role of Troponin and Stress Testing

• The use of high-sensitive troponin assays can help in the early diagnosis of acute myocardial infarction 3.
• Stress testing, such as exercise treadmill stress test or nuclear stress test, can be used to evaluate patients with atypical chest pain and non-diagnostic ECG 4, 5.
• According to 4, a 2-hour accelerated protocol using high sensitivity Troponin assay at 0 and 2 hours with comprehensive clinical evaluation and ECG followed by stress testing might be successful in identifying low-risk patient population who may benefit from early discharge from ED.
• Stress echocardiography is superior to exercise ECG in the risk stratification of patients presenting with acute chest pain with negative Troponin 5.

Clinical Decision-Making

• Distinguishing early repolarization from subtle ST-segment elevation myocardial infarction (STEMI) in patients with acute chest pain can be challenging 6.
• A good clinical acumen, along with a comparison of prior ECGs, can aid in decision-making 6.
• The patient's clinical presentation, ECG findings, and cardiac biomarkers must be carefully evaluated to determine the underlying cause of the chest pain and to guide further management.