What is Benign Early Repolarisation?

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

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

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.

Print Friendly

Comments

  1. nstru says

    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.

    • Peter Allely says

      Agree completely -- the patient groups are highly selected and the cynic inside of me wonders if they were written to garner press attention…..

  2. Sa'ad Lahri says

    Hi!
    thanks for a great post! I do appreciate the posting was about BER but…
    In the above ecg, I was just concerned about the T wave inversion in AVL
    Did serial ECG’s reveal anything sinister? T wave inversion may represent a reciprocal change in inferior MI and may precede a full blown ecg changes associated with an inferior MI

    Warmest regards
    Sa’ad

    • Peter Allely says

      Hi Sa’ad,
      I have to admit the ECG was actually from an 18 year old girl following a paracetamol overdose, so no concerns about an inferior MI in this particular case.
      thanks for the comment.
      Peter

  3. says

    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

    • says

      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

  4. says

    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?!

  5. Dr. ashok Dutta says

    BER is diagnosed by STE in primordial leads only.
    If its in inferior leads or is associated with chest discomfort, don’t take it benign.

Comments