The document discusses early repolarization (ER), which was historically thought to be benign but is now known to be linked to arrhythmias and sudden cardiac death. It defines ER based on criteria from consensus papers and discusses risk stratification challenges. ER exists on a spectrum with Brugada syndrome and shares similarities in pathogenesis. While ER in anterior leads may carry less risk, inferior/lateral ER is more likely to be associated with higher risk. Symptomatic early repolarization syndrome merits ICD implantation, while asymptomatic cases require close follow up. Management can include beta blockers or other drugs.

1. Early Repolarisation.
B Y S I M O N M A R K D A L E Y ( 2 0 1 8 )
A 'quick-lit-review.'
(Not so benign)

2. EARLY REPOLARISATION.. (ER)
Also historically referred to as ‘high take off’ - this term is outdated.
Up to 15% of chest pain presentations to the ED will have ER.
More common <50yrs, less common >70yrs.
Physiological basis remains poorly understood.
Historically thought to be benign. In the past 20 years multiple
studies have shown a link to threatening arrhythmia and sudden
cardiac death (SCD).
Risk stratification remains challenging & controversial, although
increasingly less so.

3. IS THERE AN ER DEFINITION?
A 2015 consensus paper recommended that a new definition was
urgently needed. It proposed the below criteria, which subsequently
was reiterated by a further consensus meeting in 2016;
ERP is present if the following criteria are met;
There is end-QRS notch or slur on the downslope of a prominent
R-wave. If there is a notch, it should lie entirely above the
baseline. The onset of a slur must also be above the baseline.
J-point is >0.1mV in 2 or more contiguous leads, excluding v1-v3.
QRS duration is <120ms.
ST elevation in the absence of a notched or slurred J-point should not
be described as ER.
a.
b.
c.
Macfarlane et al (2015)
Antzelevitch et al (2016)

4. ?ERP IN v1-v3
When ERP/non-specific ST-
segment elevation is present
in these leads, give careful
consideration to differential
diagnoses.
Antzelevitch et al (2016)

5. TERMINOLOGY / CLASSIFICATIONS.
The accuracy of categorisation is of importance, and should be
standardised.
If the ST-segment is upward sloping and followed by an upright T-
wave, the pattern should be described as “early repolarization with
an ascending ST segment.”
If the ST-segment is horizontal or downward sloping, the pattern
should be described as “early repolarisation with a horizontal or
descending ST segment.”
The leads in which the notching or slurring occurs should be used as
part of the description, so that, for example, a complete report might
state, “early repolarisation with descending ST-segment in leads II,
III, and aVF.” Antzelevitch et al (2016)Macfarlane et al (2015)

6. ER PATTERN vs
ER SYNDROME.
Early repolarisation syndrome is diagnosed
when there is ERP in the inferior/lateral
leads presenting with aborted cardiac
arrest, VF or polymorphic VT.
Antzelevitch et al (2016)
Macfarlane et al (2015)
Antzelevitchetal(2016)

7. PATHOPHYSIOLOGY OF
ERS (&BrS).
Early repolarisation syndrome lies on a spectrum with BrS; Many
clinical similarities – suggesting similar pathophysiology.
Males predominate both syndromes (71% of BrS & 80% of ERS).
Incidence of VF highest in third decade of life; ?linked to testosterone.
ERP is prevalent in Africans/African-Americans, but apparently not
associated with high risk.

8. RISK STRATIFICATION.
Studies have shown that ER – especially in the inferior leads –
predicts cardiac and arrhythmic death.
The incidental discovery of a J-wave should not be interpreted as a
marker of ‘high risk’ for SCD since the odds are extremely low.
Presence of a J-wave on the ECG may increase the probability of VF
from 3.4:100,000 to 11:100,000.
Viskin et al (2014).
Rosso et al (2011).

9. J WAVE MANIFESTATION.
Antzelevitchetal(2016)

10. MANAGEMENT.
ßeta-blockers can suppress electrical
storms and associated J-wave
manifestations.
Long-term therapy using quinidine,
bepridil, denopamine, & cilostazol is
reported to suppress the development
of VF/VT in both.
Antzelevitchetal(2016)

11. TAKE HOME POINTS.
ER can no longer assumed to be benign.
ERS lies on a spectrum with BrS.
ERP in the anterior leads appears more likely to be ‘benign’, with
inferior/lateral ERP more likely to be high risk. Care must still be taken
when labelling anterior ER/non-specific STE as "BER".
Symptomatic ERS is an indication for ICD implantation.
In the absence of syncope, or a strong family history of
sudden cardiac death (SCD), the finding of the ERP does not
merit further investigation. Asymptomatic ERS should receive
‘close’ follow up.

12. https://www.ncbi.nlm.nih.gov/pubmed/26205599
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4927622/
https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000388
https://www.ncbi.nlm.nih.gov/pubmed/21295159
REFERENCES.