Benign early repolarization is seen in 2-5% of the population, usually young physically fit individuals, and is characterized by J-point notching and concave-up ST elevation less than 3mm that decreases with increased heart rate. However, some recent studies have questioned whether it is truly benign, finding an association with increased risk of cardiac events. The diagnosis requires clinical context and exclusion of other possibilities, as features alone do not confirm benign early repolarization.

1. BENIGN EARLY
REPOLARIZATION
(…BUT IS IT REALLY BENIGN?)

2. WHO GETS IT?
• 2-5% of the general population (Wellens, 2008)
• Usually the young and physically fit
• Generally disappears with advancing age
• Don’t forget clinical context, a 45yr old with <2mm
STE in a BER morphology w/o sxs concerning for ACS
can still be BER

3. WHAT IS IT?
• The truth of the matter is…we aren’t too sure!
• Nerdy answer:
• Experimental data shows pts with BER to have
heterogeneous repolarization physiology with myocytes
containing a larger concentration of transient outward
current, inducing a voltage gradient during the ST segment
(Kusumoto, Cardiovascular Pathophysiology, 2006)
• What to tell your patient:
• This is a normal, benign variation that we see in a lot of
patients that has no clinical significance

4. WHAT DOES IT LOOK LIKE?
Red arrows: concave up ST-segment elevation anteriorly
Blue arrows: hyperdynamic, symmetrical, concordant T-waves

5. CLASSIC FINDINGS
1. J-point “notching”
2. Concave-up ST
segment (smiley
face)
3. ST segment elevation
from baseline in
V2-V5, typically
<3mm
4. Large, symmetrically
concordant T-waves
in leads with STE

6. CAN WE TEASE IT OUT?
• The degree of ST segment elevation is thought to be
indirectly proportional to the degree of sympathetic
tone
• In other words, the more relaxed the patient, the
more pronounced the ST segment elevation (and
vice versa)
• If you truly want to test your patient, get their heart
rate up and look at the ST segment

7. 14yo M w/ palpitations
HR: 64

8. 1. Notched
J-point
2. Concave
down ST
elevation in
precordial
leads

9. Same patient after asking him to do 2min of jumping jacks in the
room to try and get his heart rate up…
HR 83 (up 20bpm from previous)

10. HR 64 HR 83
The ST segment is NOT fixed in pts w/ BER and changes from EKG to EKG
and with the degree of sympathetic strain
On the right, note the complete resolution of the ST elevation but
maintenance of the J-point notching in V4

11. TO BER, OR NOT TO BER…THAT IS THE
QUESTION!
• New studies are suggesting BER is not always so
benign…
• http://www.nejm.org/doi/full/10.1056/NEJMoa071968#t=article
• http://www.nejm.org/doi/full/10.1056/NEJMoa0907589
• But before you go working up every case of BER
because of these papers, know this…
• These are far from conclusive papers!
• One is a retrospective review of 206 patients after an episode of
VF (Haissaguerre, et al)
• The other suggests repolarization in the inferior leads in middle
aged people was associated with increased risk of cardiac
death in the long-term, with only a relative risk of <3!
(Tikkanen, et al)

12. IN CONCLUSION
• BER should be a diagnosis of exclusion and should ALWAYS be placed
in clinical context!!!
• The above was taken in a patient with difficulty breathing and chest
pain…and is an AMI, NOT BER!!!
• Note the hyperacute T-waves (disproportionately larger than the
QRS complex, developing q-waves, and lack of J-point notching)