A 26 year old presents to your ED with central chest tightness. He has no risk factors and looks pretty well. The Nurse hands you his ECG. You pattern recognise it as ‘Benign Early Repolarisation’ and smugly sign the ECG. After the nurse has gone your resident asks you what it is.
Benign Early Repolarisation
Thankfully the Bat phone goes off and you pretend to be too busy preparing to look after the triply incontinent bed bound demented 103 year old about to arrive with ?constipation. Annoyingly, after you’ve managed to get the above mentioned patient back to tax payer status, the resident corners you and again asks you ‘What is Benign Early Repolarisation’? Time for a brief review…
Benign Early Repolarisation
Early Repolarisation (AKA ‘benign early repolarisation’, ‘High uptake’, ‘J point elevation’, to name but a few…!) was first described by Shipley in 1936 and occurs in 2-5% of the general population.
J point notching
Features:
- Common in Fit Young people.
- Generally disappears in middle age, rare in the elderly.
- Elevated J Point, often with notching.
- Predominantly in anterior chest leads, but can occur elsewhere.
- Associated with large, symmetrical, concordant T waves.
- Absence of reciprocal changes or pathological Q waves.
- Possibly related to high sympathetic tone on heart – can normalise with exercise or Beta-Blockade.
Recent NEJM papers (here + here) suggested this ECG pattern is not as benign as has been suggested in the past, however these are far from conclusive papers, with one being a retrospective review of 206 patients after an episode of VF and the other suggesting repolarisation in the inferior leads in middle aged people was associated with increased risk of cardiac death in the longterm (but with only a relative risk of <3).
So try and avoid diagnosing benign early repolarisation in middle aged people, especially those with central crushing chest pain and you’ll be fine. For a typically brilliant video review visit EMRAP TV here.
About Peter Allely
I find the recent literature that suggests BER may not be so benign misleading. The increase in sudden cardiac death in young men with repol-like STE inferiorly sounds concerning, but generally BER is a precordial finding, and STE in the inferior (or limb) leads isn’t classified as BER in the first place.
Yet again using your amazing database for learning, thx!!
A trivial but important notice: the prominent T waves would be *A*symmetric since symmetric T-waves indicate pathology (ischemia/stroke);
“The normal T wave rises slowly and then abruptly returns to baseline (slightly asymmetrical)”
(we still want to believe early repolarization is benign -- although it might be changing according to latest literature!)
ref
http://www.kallus.com/er/resident/julycourse/reading/non%20cardiac%20ST-T%20changes.pdf
Hi David
Symmetry is relative…
The paper by Brady that you reference states that symmetric T waves is a feature of BER, then in a subsequent paragraph states that they are slight asymmetric.
A fat asymmetric tall T wave is more suggestive of hyperacute T wave in MI, whereas a narrow-based symmetrical, peaked T wave indicates hyperkalemia. BER T waves are more intermediate between the two. As Stephen Smith’s blog often emphasises (click here for Dr Smith’s BER posts), QT is also important -- should be short in hyperK, longer in MI, and again probably intermediate in BER (rarely QTc >455 ms). Also tall precordial R waves suggests BER over MI, as does the presence of concave up ST elevation of <2mm with no reciprocal ST depression. EMRAP.TV’s brief video on tall T’s is also worth a look: http://emrap.tv/index.php?option=com_content&view=article&id=134:EMRAPTV34-BigTwaves
Cheers
Chris
Aha… hadn’t spotted that, seems like a little blurry then… fortunately we all agree on the tall T wave!
Dr Smith is just amazing, I am waiting for his final call on QTc and acute MI, if I remember correctly he has some really potential research material waiting for publication there. I find his thoughts about ischemia not localizing even more exciting
http://hqmeded-ecg.blogspot.com/2009/01/st-depression-limited-to-inferior-leads.html
it puts a completely new perspective on that ST depression with chest pain; reciprocal change or localised ischemia -- or maybe just the same thing?!
so thanks