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.
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.
- 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.