From the Guidelines
Early repolarization on a pre-operative EKG is generally considered a benign finding that does not require specific intervention or delay of surgery. This pattern appears as ST-segment elevation (usually 1-3mm) in multiple leads, particularly the precordial leads, with concave upward ST segments and prominent T waves. According to the 2018 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1, the prevalence of an early repolarization pattern on ECG with J point elevation in the inferior or lateral leads of at least 0.1 mV has been reported to be as high as 5.8% in adults. However, it is essential to rule out reversible causes such as ischemia, as patients with early repolarization are more susceptible to the development of VF during acute cardiac ischemia and/or in the presence of QRS abnormalities due to LV hypertrophy or bundle-branch block 1.
The anesthesiologist and surgical team should be informed of this finding, but it should be clearly distinguished from concerning patterns like acute myocardial infarction or pericarditis. The key distinguishing features include the concave upward shape of the ST elevation, absence of reciprocal ST depression, and lack of clinical symptoms. If there is any uncertainty about whether the pattern represents early repolarization versus a pathological condition, consultation with a cardiologist prior to surgery may be warranted, especially if the patient has risk factors for cardiac disease or symptoms. The 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1 suggests that a preoperative 12-lead ECG is likely to be more valuable for patients planned for elevated-risk surgical procedures, particularly for those with known coronary heart disease, arrhythmias, peripheral arterial disease, cerebrovascular disease, or other significant structural heart disease.
In terms of management, no specific medications or treatments are needed for early repolarization, as it is a normal variant found in approximately 5-13% of the general population, more commonly in young, athletic males and individuals of African descent. The focus should be on standard monitoring and ensuring that the patient's overall cardiovascular risk is assessed and managed accordingly. Overall, early repolarization on a pre-operative EKG does not typically require any changes to the surgical plan, and surgery can proceed as planned with standard monitoring, unless there are other concerning factors or uncertainties that require further evaluation.
From the Research
Early Repolarization Pre-Op EKG
- Early repolarization has been associated with idiopathic ventricular fibrillation and arrhythmic death, as noted in a study published in 2015 2.
- The prevalence of early repolarization in the general population is estimated to be between 3-13% 2.
- Characteristics associated with a high risk of early repolarization include high-amplitude J-point elevation, horizontal/descending ST segment, and inferior lead location 2.
- A syndrome termed 'early repolarization syndrome' (ERS) has been accepted as a cause of cardiac arrest in patients with a pronounced early repolarization pattern and an otherwise structurally normal heart 2.
Diagnostic Approach
- An early repolarization pattern can be observed in 1% up to 13% of the overall population, and while it was once considered benign, recent studies have demonstrated an association with sudden cardiac death 3.
- The isolated presence of an early repolarization pattern does not require further intervention, but more precise tools for risk stratification and identification of high-risk patients are needed 3.
- Early repolarization can be distinguished from other conditions, such as acute myocardial infarction or pericarditis, by its normalization with exercise, as shown in a study published in 1995 4.
Prognosis and Risk Stratification
- Patients with early repolarization are more likely to be male, younger, and athletically active, but the long-term prognosis is generally benign 5.
- A consensus paper published in 2015 established an agreed definition of early repolarization, which requires a peak of an end-QRS notch and/or the onset of an end-QRS slur as a measure, denoted Jp, to be determined when an interpretation of early repolarization is being considered 6.
- The risk of sudden cardiac death associated with early repolarization is still a topic of ongoing research, and further studies are needed to fully understand the implications of this electrocardiographic pattern 2, 3.