Epidemiology

  ER is observed in approximately 1-9% of the general population.

  ER is observed in 15-70% of the cases with idiopathic ventricular fibrillation (VF).

  ER is 3 times more frequent in men.

  ER is more frequently observed in blacks.

  More than 90% of well-trained athletes have ER.



ECG findings

  At least 2 contiguous leads must show upwardly concave ST segment elevation.

  J wave (notching or slurring of the QRS complex) may accompany (71%).

  Prominent T waves may accompany.



Clinical significance

  ER may involve different leads.

  Localization of the ER has been reported to affect prognosis.

  In asymptomatic individuals observation of ER in mid-precordial leads (V2, V3, V4) has been reported NOT to increase the arrhythmic risk. Well-trained athletes frequently have this type of ER.

  Observation of > 0.2mV (> 2mm on standard ECG) ST elevation in inferior leads has been reported to increase the risk of sudden cardiac death 3 times.

  Observation of ER in inferior and lateral leads show even more risk of sudden cardiac death.

  Elevation of J point amplitude is freqently observed before attacks of VF.

  A high prevalence of ER was reported in patients with Short QT Syndrome.



Lability of ER

  Heart rate and vagal tone affects ER.

  In the presence of increased vagal tone or decreased heart rate (after meals or during sleep) the risk of ER-related idiopathic VF may increase.

  The ER pattern may decrease or even disappear during adrenergic stimulation (exercise). Exercise may also decrease arrhythmia risk.



Common aspects of ER and Brugada Syndrome

  More frequently observed in males.

  ST elevation and J wave are observed.

  Arrhythmic events

o frequently occur in ages of 35-45 years.
o frequently occur during bradycardia.
o decrease by Quinidine or Isoproterenol.



References

  Heart Rhythm 2010;7:647-652.

  N Engl J Med 2009;361:2529-37.

  Anatol J Cardiol 2018;20(1):61-63

  N Engl J Med 2008;358:2078-9.

  N Engl J Med 2008;358:2016-23.

  J Am Coll Cardiol 2010;56:1177-86.

  Journal of Electrocardiology 2012;45:404-410.




ECG 1. ER in an apparently healthy 39 years-old man. ER is more frequently observed in midprecordial leads (C3 and C4).
In ER, two aspects of ST elevation differentiate it from the ST elevation of myocardial infarction: In ER, J point is elevated and
the ST segment is upwardly concave .

The observation of ER in MID PRECORDIAL leads (V2, V3, V4) is generally regarded as having a benign prognosis.

J point : The point where S wave meets the ST segment.

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ECG 2. The ECG above belongs to a 19 years-old apparently healthy man. The J waves in V4, V5 and V6 suggest ER.

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ECG 3. The ECG above belongs to a 48 years-old man. ST elevation in anterior leads and prominent T waves are seen.
The absence of PR segment elevation/depression rules out the diagnosis of pericarditis.

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ECG 4. The ECG above belongs to a 69 years-old man with normal coronary arteries. The J wave is best seen in lead C3.
The leads C2, C3 and C4 show prominent T waves.

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ECG 5. The ECG above belongs to a 23 years-old man with no known disease. The J wave is best observed in lead C4. Leads II
and aVF also have upwardly concave ST segment elevation. There is no PR segment elevation or depression to suggest
pericarditis.

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ECG 6. The ECG above belongs to an apparently healthy 20 years-old man. Inferior leads show J wave and ST segment
elevation. If ER is localized to inferior or inferior + lateral leads and there is accompanying ST segment elevation > 2mm,
the risk of sudden cardiac death increases 3-fold. ER may become more prominent during bradycardia.

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ECG 7. The ECG above belongs to a 35 years-old showing J wave , ST segment elevation and prominent T waves in
mid-precordial leads. This pattern of ER DOES NOT INCREASE the risk of sudden cardiac death.

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ECG 8a. The Holter tracing above show how labile ER is. At 00:06 when heart rate increases up to 80s ER pattern almost
disappears . At 02:34, when heart rate decreses down to 50s ER pattern becomes more clear .

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ECG 8b. The same patient's Holter tracing, 2-3 minutes later. When heart rate decreses down to 50s the ER pattern becomes
obvious , when heart rate increases up to 80s the ER pattern almost disappears .

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ECG 9a. The ECG above belongs to a 57 years-old man who does not have any significant coronary artery disease.
The inferior leads show J waves : early repolarization.

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ECG 9b. J waves of the same patient.




ECG 10a. The ECG above belongs to a 68 years-old woman with atrial fibrillation and normal coronary arteries.
Extreme early repolarization is seen.

Dr. Ertan Vuruşkan has donated the above ECG to our website.
The Anatolian Journal of Cardiology has permitted to use the above ECG.

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Click here to read the relevant article by Dr Ertan Vuruşkan



ECG 10b. The ECG above belomngs to the same patient. It was recorded one day after ECG 10a.
ST elevation persists. No change in ST elevation pattern further supports the diagnosis of early repolarization. .

Dr. Ertan Vuruşkan has donated the above ECG to our website.
The Anatolian Journal of Cardiology has permitted to use the above ECG.

Click here for a more detailed ECG

Click here to read the relevant article by Dr Ertan Vuruşkan




ECG 11. The ECG above belongs to a 57 years-old man with diabetes mellitus and hypertension.
He was complaining of chest oppression in the last several months.
Coronary angiography did not show significant coronary artery stenosis: only mild plaques in the LAD and Cx arteries,
and slow flow with 60% stenosis in the RCA.
Leads V2 to V5 show ST segment elevation compatible with early repolarization.

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ECG 12a. The ECG above belongs to a 45 years-old man. He was complaining of chest oppression for the last 4 hours.
Leads V1 to V4 show ST segment elevation and tall T waves. There are no leads showing reciprocal ST depression.
Does this ECG show early repolarization or acute anterior myocardial infarction?
What if a person with early repolarization pattern on ECG experiences acute anterior myocardial infarction?
In the above ECG, lead V2 shows 5 mm (0.5 mV) ST segment elevation, unusual for early repolarization.
Also, the T wave in lead V2 is taller than the preceding R wave.
These findings are not typical for early repolarization.
Immediately after recording of the above ECG, the patient underwent urgent coronary angiography.
The LAD (Left Anterior Descending) coronary artery had 98% stenosis after giving off its first Diagonal branch.
The stenotic LAD coronary artery was successfully stented.

The above ECG was donated by Dr. Ersin Sarıcam to our website.

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ECG 12b. The ECG above belongs to the same patient. It was recorded after successful stenting of the LAD coronary artery.
(35 minutes after the ECG 12a). Now, the ST segment elevation and T wave amplitude are decreased.

The above ECG was donated by Dr. Ersin Sarıcam to our website.

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ECG 12c. The ECG above belongs to the same patient. It was recorded 32 hours after the ECG 12a.

The above ECG was donated by Dr. Ersin Sarıcam to our website.

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