What are the electrocardiographic (ECG) criteria for diagnosing benign early repolarisation?

Benign Early Repolarization Criteria

Benign early repolarization is defined as elevation of the QRS-ST junction (J-point) by ≥ 0.1 mV often associated with a late QRS slurring or notching (J-wave) affecting the inferior and/or lateral leads. 1

Key Diagnostic Criteria

Primary ECG Features

• J-point elevation ≥ 0.1 mV (1 mm) from baseline in at least two contiguous leads 1
• Terminal QRS slurring or notching (J-wave) 1
• Most commonly affects inferior (II, III, aVF) and/or lateral leads (I, aVL, V4-V6) 1

ST Segment Characteristics

• Concave upward (upward sloping) ST-segment elevation 1
• Absence of reciprocal ST depression (except possibly in aVR) 2
• ST-segment elevation often most prominent in mid-to-lateral precordial leads (V3-V4) 1

T Wave Features

• Concordant T waves of large amplitude ("peaked and tall" T-waves) 1, 3
• In Caucasians: elevated ST-segment with upward concavity ending in positive T-wave 1
• In Black athletes: ST-segment elevation followed by T-wave inversion confined to leads V2-V4 can be a normal variant 1

Distribution and Prevalence

• Common in healthy populations (2-44%) 1
• Higher prevalence in:
  • Athletes (50-80% of resting ECGs) 1
  • Young individuals 1
  • Males 1
  • Black ethnicity (63-91% of black athletes) 1

Distinguishing Features from Pathological Conditions

• Absence of reciprocal ST changes in multiple leads (reciprocal changes in multiple leads suggest acute coronary syndrome) 2
• Temporal stability of the ST segment and T wave patterns 2
• Normalization of ST-segment and T-wave changes during exercise or adrenergic stimulation 1
• Absence of concerning clinical markers (syncope, family history of sudden cardiac death) 1

Benign vs. Malignant Early Repolarization

• Benign patterns typically show:

  • Concave upward ST-segment elevation 1, 3
  • Widespread ST elevation (precordial greater than limb leads) 4
  • Stable ECG pattern over time 2, 4

• Features suggesting potentially malignant forms:

  • Horizontal or downsloping ST segments after J-point elevation 2
  • J-wave amplitude >2 mm 2
  • Dynamic or dramatic changes in J-wave morphology (especially at night) 2
  • "Lambda-wave" ST shape 2
  • Premature ventricular contractions with very short coupling 2

Clinical Implications

• Based on current evidence, all patterns of early repolarization, when present in isolation and without clinical markers of pathology, should be considered benign variants 1
• No data currently support an association between inferior early repolarization and sudden cardiac death in athletes 1
• Further evaluation is not required in asymptomatic individuals with isolated early repolarization pattern 1

Common Pitfalls in Diagnosis

• Misdiagnosis as acute myocardial infarction, especially in emergency settings 4
• Failure to recognize normal variant patterns in athletes and young individuals 1
• Overdiagnosis in Black individuals who may have normal ST elevation with T-wave inversion in V2-V4 1
• Confusion with Brugada pattern (which shows downsloping ST-segment followed by negative 'coved' or positive 'saddle-back' T-wave in V1-V2) 1