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Different types of early repolarization. (A) Demonstrates slurred early repolarization without ST-segment elevation in the inferolateral leads. (B) Demonstrates notched early repolarization without ST-segment elevation in the inferior leads. (C) Demonstrates notched early repolarization with ST-segment elevation in the inferolateral leads. This type is consistent with Wasserberger's early description.
Source publication
Early repolarization (ER) has historically been considered a benign electrocardiogram (ECG) variant, and is seen more commonly in young males and individuals who undertake high levels of athletic activity and/or are of black ethnicity.1 It has recently, however, been proposed as a marker for an increased risk of sudden cardiac death (SCD). In parti...
Contexts in source publication
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... are similarities between ER syndrome and Brugada syn- drome including male predominance, peak incidence of SCD in the fourth decade, and response to isoproterenol and quini- dine. 2,7,8 Loss-of-function calcium channel mutations have been described in both. 9 This has led to the suggestion that ER and Brugada syndrome form part of a spectrum of repolarization dis- order called the 'J-wave syndromes'. 10 However, important differ- ences exist, including the response to sodium channel blocker administration and body temperature. Sodium channel blockers are used routinely in the diagnosis of Brugada syndrome to unmask right precordial ST-segment elevation on the ECG, but existing data in ER has demonstrated a variable response with accentuation of ER changes in only a minority of cases. 2,8,11,12 Brugada syndrome can be exacerbated by pyrexia while ER syn- drome has been reported to be exacerbated by hypothermia. 13 Not all ER is necessarily the same, however. Wellens, for example, questioned whether J-point elevation with slurring or notching seen independently of ST elevation was indeed ER or in fact delayed activation of the inferolateral left ventricular wall. 2,14 In a recent study by Tikkanen et al. 15 comparing the general population with athletes, the increased risk of SCD in ER was associated with horizontal/descending ST-segment morphology ( Figure 1A and B) but not with a rapidly ascending ST-segment ( Figure 1C). The rapidly ascending ST-segment variant is ...
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... are similarities between ER syndrome and Brugada syn- drome including male predominance, peak incidence of SCD in the fourth decade, and response to isoproterenol and quini- dine. 2,7,8 Loss-of-function calcium channel mutations have been described in both. 9 This has led to the suggestion that ER and Brugada syndrome form part of a spectrum of repolarization dis- order called the 'J-wave syndromes'. 10 However, important differ- ences exist, including the response to sodium channel blocker administration and body temperature. Sodium channel blockers are used routinely in the diagnosis of Brugada syndrome to unmask right precordial ST-segment elevation on the ECG, but existing data in ER has demonstrated a variable response with accentuation of ER changes in only a minority of cases. 2,8,11,12 Brugada syndrome can be exacerbated by pyrexia while ER syn- drome has been reported to be exacerbated by hypothermia. 13 Not all ER is necessarily the same, however. Wellens, for example, questioned whether J-point elevation with slurring or notching seen independently of ST elevation was indeed ER or in fact delayed activation of the inferolateral left ventricular wall. 2,14 In a recent study by Tikkanen et al. 15 comparing the general population with athletes, the increased risk of SCD in ER was associated with horizontal/descending ST-segment morphology ( Figure 1A and B) but not with a rapidly ascending ST-segment ( Figure 1C). The rapidly ascending ST-segment variant is ...
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... definition of ER has evolved. It was defined by Wasserburger 1 in 1961 as elevated take-off of the ST-segment at the end of the QRS (the J junction) with downward concavity of the ST-segment and symmetrical T-waves seen particularly in the lateral ECG leads ( Figure 1C). In 2008, it was redefined by Haissaguerre et al. 2 in the New England Journal of Medicine. The new definition, which has been used exclusively since, requires J-point elevation of at least 0.1 mV in two leads with a slurred or notched appearance, but concomitant ST-segment elevation is not necessary ( Figure 1A and B). The prevalence of ER in the general population has there- fore altered accordingly, being 122% when assessed using the original definition, 1,4 but ranging from 6 to 13% since 2008. 3,5 Difficulties measuring the terminal QRS Accurate measurement of ER depends upon sharp transition of the terminal QRS complex into the ST-segment. This is usually straightforward in notched ER but frequently unclear in slurred ER ( Figure 1A and B). When there is a gradual transition at the end of the QRS complex, J-point definition is more subjective. In this situation, the discrepancy of repeated QRS interval measure- ments has been shown to approach as much as 40 ms. 6 In addition, the QRS complex may begin and end at different times in different ECG leads. Leads where the QRS begins earliest are often not the same leads where it ends latest, with up to a 20 ms difference. 6 Therefore, what may appear as notching of the terminal QRS and ER in one ECG territory may look like QRS fragmentation and conduction delay in another ( Figure ...
Context 4
... definition of ER has evolved. It was defined by Wasserburger 1 in 1961 as elevated take-off of the ST-segment at the end of the QRS (the J junction) with downward concavity of the ST-segment and symmetrical T-waves seen particularly in the lateral ECG leads ( Figure 1C). In 2008, it was redefined by Haissaguerre et al. 2 in the New England Journal of Medicine. The new definition, which has been used exclusively since, requires J-point elevation of at least 0.1 mV in two leads with a slurred or notched appearance, but concomitant ST-segment elevation is not necessary ( Figure 1A and B). The prevalence of ER in the general population has there- fore altered accordingly, being 122% when assessed using the original definition, 1,4 but ranging from 6 to 13% since 2008. 3,5 Difficulties measuring the terminal QRS Accurate measurement of ER depends upon sharp transition of the terminal QRS complex into the ST-segment. This is usually straightforward in notched ER but frequently unclear in slurred ER ( Figure 1A and B). When there is a gradual transition at the end of the QRS complex, J-point definition is more subjective. In this situation, the discrepancy of repeated QRS interval measure- ments has been shown to approach as much as 40 ms. 6 In addition, the QRS complex may begin and end at different times in different ECG leads. Leads where the QRS begins earliest are often not the same leads where it ends latest, with up to a 20 ms difference. 6 Therefore, what may appear as notching of the terminal QRS and ER in one ECG territory may look like QRS fragmentation and conduction delay in another ( Figure ...
Context 5
... definition of ER has evolved. It was defined by Wasserburger 1 in 1961 as elevated take-off of the ST-segment at the end of the QRS (the J junction) with downward concavity of the ST-segment and symmetrical T-waves seen particularly in the lateral ECG leads ( Figure 1C). In 2008, it was redefined by Haissaguerre et al. 2 in the New England Journal of Medicine. The new definition, which has been used exclusively since, requires J-point elevation of at least 0.1 mV in two leads with a slurred or notched appearance, but concomitant ST-segment elevation is not necessary ( Figure 1A and B). The prevalence of ER in the general population has there- fore altered accordingly, being 122% when assessed using the original definition, 1,4 but ranging from 6 to 13% since 2008. 3,5 Difficulties measuring the terminal QRS Accurate measurement of ER depends upon sharp transition of the terminal QRS complex into the ST-segment. This is usually straightforward in notched ER but frequently unclear in slurred ER ( Figure 1A and B). When there is a gradual transition at the end of the QRS complex, J-point definition is more subjective. In this situation, the discrepancy of repeated QRS interval measure- ments has been shown to approach as much as 40 ms. 6 In addition, the QRS complex may begin and end at different times in different ECG leads. Leads where the QRS begins earliest are often not the same leads where it ends latest, with up to a 20 ms difference. 6 Therefore, what may appear as notching of the terminal QRS and ER in one ECG territory may look like QRS fragmentation and conduction delay in another ( Figure ...
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Electrocardiographic changes in athletes are common and usually reflect benign structural and electrical remodelling of the heart as a physiological adaptation to regular and sustained physical training (athlete's heart). The ability to identify an abnormality on the 12-lead ECG, suggestive of underlying cardiac disease associated with sudden cardi...
Citations
... T he early repolarization (ER) pattern is a common electrocardiographic finding that has been historically considered benign. However, there is a growing body of evidence to suggest that ER carries an increased risk of sudden death, especially if localized in the inferior leads with a horizontal and/or descending ST segment (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11). The pathophysiology underlying ER and J-wave development remains uncertain; however, it has been suggested to be secondary to transmural dispersion of repolarization that involves the transient outward current (I to ) (12). ...
... ER is a notching or slurring morphology of the terminal QRS in at least two contiguous inferior or lateral leads [16,38,39], as depicted in Fig. 8. ER can be benign or malignant. In general, malignant ER is associated with older age, a significantly longer QRS duration and increased sign of VAs [40]. A prominent J wave is a noticeable finding just before the VA onset [22,41]. ...
... A prominent J wave is a noticeable finding just before the VA onset [22,41]. In addition, a horizontal or descending ST segment is also often emphasized in reports of malignant ER [40,42]. ...
Many studies showed electrocardiogram (ECG) parameters are useful for predicting fatal ventricular arrhythmias (VAs). However, the studies have several shortcomings. Firstly, all studies lack of effective way to present behavior of various ECG parameters prior to the occurrence of the VAs. Secondly, they also lack of discussion on how to consider the parameters as abnormal. Thirdly, the reports do not include approaches to increase the detection accuracy for the abnormal patterns. The purpose of this study is to address the aforementioned issues. It identifies ten ECG parameters from various sources and then presents a review based on the identified parameters. From the review, it has been found that the increased risk of VAs can be represented by presence and certain abnormal range of the parameters. The variation of parameters range could be influenced by either gender or age. This study also has discovered the facts that averaging, outliers elimination and morphology detection algorithms can contribute to the detection accuracy.
... In the present study, spatial and transmural dispersion of repolarization did not significantly differ between ERS and ER pattern patients. Bastiaenen et al. reported that ER type may represent 2 different processes; classical benign ER may reflect earlier onset of repolarization but malignant ER may reflect abnormal depolarization, possibly due to underlying subtle structural disease [16]. Roten et al. reported that patients with recurrent VF have significantly higher inferior/global J wave amplitudes, inferior J wave amplitudes, high lateral J wave amplitudes, and lateral J wave amplitudes than patients without VF recurrences, but differences in ST segment morphology, T peak ÀT end interval, and T peak ÀT end /QT ratio in lead V5 were not associated with recurrent VF [17]. ...
Background
Electrophysiological characteristics of early repolarization syndrome (ERS), i.e., the spatial and transmural dispersion of ventricular repolarization and ventricular late potentials can be evaluated using a signal-averaged vector-projected 187-channel high-resolution electrocardiogram (187-ch SAVP-ECG). We investigated these characteristics as markers of ventricular fibrillation and sudden cardiac arrest in patients presenting with an ER pattern.
Methods
The 187-ch SAVP-ECGs were recorded for 8 patients with idiopathic ventricular fibrillation associated with ERS (ERS patients), and 5 patients with an ER pattern without arrhythmic events (ER pattern patients).
Results
The ER pattern was located in the inferior leads (n=7), lateral leads (n=1), or both inferior and lateral leads (n=5). The corrected RT(RTc) (peak point of the R wave − positive maximum peak of the first derivative of the T wave interval corrected using the Bazett formula) interval and T(peak-end)-c interval from the 187 channels were calculated. Late potentials were positive in 7 of 8 ERS patients and in 3 of 5ER pattern patients (P=0.25). The average RTc was shorter in patients with ERS (192.6±29.8 ms vs. 234.0±25.5 ms, P=0.04). However, average T(peak-end)-c interval did not differ between the 2 groups.
Conclusion
Late ventricular potentials were common in ERS and ER pattern patients. Lethal arrhythmia in ERS patients appeared to be related to the relatively short average repolarization time rather than the spatial and transmural dispersion of repolarization.
... . In particular, further investigations have shown that the increased risk of arrhythmic death is mainly related to ER patterns with horizontal or descending ST segments [7]. It has been postulated that these malignant ER patterns reflect abnormal depolarization, possibly due to underlying subtle structural disease, rather than earlier onset of repolarization [8]. ...
Background:
Early repolarization (ER) is a risk marker for sudden cardiac death. Higher risk is associated with horizontal/descending ST-segment ER in the inferior or inferolateral ECG leads. Studies in family cohorts have demonstrated substantial heritability for the ER pattern, but genome-wide association studies (GWAS) have failed to identify statistically significant and replicable genetic signals.
Methods and results:
We assessed the narrow-sense and common single nucleotide polymorphism (SNP) heritability of ER and ER subtypes using ECG data from 5829 individuals (TwinsUK, BRIGHT and GRAPHIC cohorts). ER prevalence was 8.3%. In 455 monozygous vs 808 dizygous twin pairs, concordances and twin correlations for ER subtypes (except horizontal/descending ST-segment ER) were higher and familial resemblance (except notched ER) was significant. Narrow-sense heritability estimates derived from 1263 female twin pairs using the structural equation program Mx ranged from 0.00-0.47 and common SNP heritability estimates derived from 4009 unrelated individuals of both sexes using Genome-wide Restricted Maximum Likelihood (GREML) ranged from 0.00-0.36, but none were statistically significant.
Conclusion:
From our data, ER shows limited genetic predisposition. There appears to be significant environmental influence and these modest narrow-sense and common SNP heritability estimates may explain why previous GWAS have been unsuccessful.
The concept of J wave syndromes was first proposed in 2004 by Yan et al for a spectrum of electrocardiographic (ECG) manifestations of prominent J waves that are associated with a potential to predispose affected individuals to ventricular fibrillation (VF). Although the concept of J wave syndromes is widely used and accepted, there has been tremendous debate over the definition of J wave, its ionic and cellular basis and arrhythmogenic mechanism. In this review article, we attempted to discuss the history from which the concept of J wave syndromes (JWS) is evolved and current controversies in JWS.
This editorial refers to 'Early repolarization pattern is the strongest predictor of arrhythmia recurrence in patients with idiopathic ventricular fibrillation: results from a single centre long-term follow-up over 20 years' by J. Siebermair et al., on pages 718-725.
Early repolarization syndrome (ERS) was previously considered as a benign variant, but it has recently emerged as a risk marker for idiopathic ventricular fibrillation (VF) and sudden death. As measured by electrocardiogram (ECG), early repolarization is characterized by an elevation of the J point and/or ST segment from the baseline by at least 0.1 mV in at least two adjoining leads. In particular, early repolarization detected by inferior ECG leads was found to be associated with idiopathic VF and has been termed as ERS. This condition is mainly observed in young men, athletes, and blacks. Also, it has become evident that electrocardiographic territory, degree of J-point elevation, and ST-segment morphology are associated with different levels of risk for subsequent ventricular arrhythmia. However, it is unclear whether J waves are more strongly associated with a depolarization abnormality rather than a repolarization abnormality. Several clinical entities can cause ST-segment elevation. Therefore, clinical and ECG data are essential for differential diagnosis. At present, the data set is insufficient to allow risk stratification in asymptomatic individuals. ERS, idiopathic VF, and Brugada syndrome (known as J-wave syndromes) are three clinical conditions that share many common ECG features; however, their clinical consequences are remarkably different. This review summarizes the current electrocardiographic data concerning ERS with clinical implications.
