Benign early repolarization: Electrocardiographic manifestations and differentiation from other ST segment elevation syndromes

doi:10.1016/S0735-6757(98)90226-1

The American Journal of Emergency Medicine

Volume 16, Issue 6, October 1998, Pages 592-597

https://doi.org/10.1016/S0735-6757(98)90226-1 Get rights and content

Abstract

Early repolarization, also known as benign early repolarization (BER) or normal variant, is noted in approximately 1% of the population and in up to 48% of patients seen in the emergency department with chest pain. BER represents a benign variant of the normal electrocardiogram and is one of several syndromes producing electrocardiographic ST segment elevation. BER electrocardiographically includes diffuse or widespread ST segment elevation, upward concavity of the initial portion of the ST segment, notching or slurring of the terminal QRS complex, and concordant T waves of large amplitude. This article focuses on BER and includes a discussion of the electrocardiographic tools useful in making this diagnosis and in distinguishing BER from other ST segment elevation syndromes.

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The purpose of the present study was to analyze the prevalence of physiologic and pathologic ECG abnormalities in a cohort of young conscripts that represents the whole young generation of today.
ECGs of all Swiss citizens who underwent conscription for the army during a 29-month period were analyzed manually.
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ECG abnormalities can be found in a relatively large proportion of young individuals. Incomplete right bundle branch block, left fascicular block, and first-degree AV block are the most frequent findings. No conscript presented with atrial fibrillation or flutter.
Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction
2012, Annals of Emergency Medicine
Anterior ST-segment elevation myocardial infarction (STEMI) can be difficult to differentiate from early repolarization on the ECG. We hypothesize that, in addition to ST-segment elevation, T-wave amplitude to R-wave amplitude ratio (T-wave amplitude_avg/R-wave amplitude_avg), and R-wave amplitude in leads V2 to V4, computerized corrected QT interval (QTc) and upward concavity would help to differentiate the 2. We seek to determine which ECG measurements best distinguish STEMI versus early repolarization.
This was a retrospective study of patients with anterior STEMI (2003 to 2009) and early repolarization (2003 to 2005) at 2 urban hospitals, one of which (Minneapolis Heart Institute) receives 500 STEMI patients per year. We compared the ECGs of nonobvious (“subtle”) anterior STEMI with emergency department noncardiac chest pain patients with early repolarization. ST-segment elevation at the J point and 60 ms after the J point, T-wave amplitude, R-wave amplitude, QTc, upward concavity, J-wave notching, and T waves in V1 and V6 were measured. Multivariate logistic regression modeling was used to identify ECG measurements independently predictive of STEMI versus early repolarization in a derivation group and was subsequently validated in a separate group.
Of 355 anterior STEMIs identified, 143 were nonobvious, or subtle, compared with 171 early repolarization ECGs. ST-segment elevation was greater, R-wave amplitude lower, and T-wave amplitude_avg/R-wave amplitude_avg higher in leads V2 to V4 with STEMI versus early repolarization. Computerized QTc was also significantly longer with STEMI versus early repolarization. T-wave amplitude did not differ significantly between the groups, such that the T-wave amplitude_avg/R-wave amplitude_avg difference was entirely due to the difference in R-wave amplitude. An ECG criterion based on 3 measurements (R-wave amplitude in lead V4, ST-segment elevation 60 ms after J-point in lead V3, and QTc) was derived and validated for differentiating STEMI versus early repolarization, such that if the value of the equation ([1.196 x ST-segment elevation 60 ms after the J point in lead V3 in mm]+[0.059 x QTc in ms]–[0.326 x R-wave amplitude in lead V4 in mm]) is greater than 23.4 predicted STEMI and if less than or equal to 23.4, it predicted early repolarization in both groups, with overall sensitivity, specificity, and accuracy of 86% (95% confidence interval [CI] 79, 91), 91% (95% CI 85, 95), and 88% (95% CI 84, 92), respectively, with positive likelihood ratio 9.2 (95% CI 8.5 to 10) and negative likelihood ratio 0.1 (95% CI 0.08 to 0.3). Upward concavity, upright T wave in V1 or T wave, in V1 greater than T wave in V6, and J-wave notching did not provide important information.
R-wave amplitude is lower, ST-segment elevation greater, and QTc longer for subtle anterior STEMI versus early repolarization. In combination with other clinical data, this derived and validated ECG equation could be an important adjunct in the diagnosis of anterior STEMI.
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Acute myocardial infarction (AMI) is a not uncommon diagnosis in the emergency department. During ST-segment elevation AMI (STEMI), the electrocardiogram (ECG) typically follows a progression of abnormality, beginning with hyperacute T waves and culminating with ST-segment elevation; pathologic Q waves can appear early and/or late in the process. Other findings include T-wave inversion and ST-segment depression which can occur before, during, or after the STEMI event. The evolution of ECG through these changes can occur rapidly after coronary artery occlusion. The emergency physician should be aware of the ECG findings that characterize the evolution of an STEMI with a sound understanding of the associated pathophysiology and clinical implication. This review discusses the changing ECG during an AMI. The pathogenesis of these findings is discussed. Finally, the clinical implications at each stage are reviewed.
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Citation Excerpt :
Second and perhaps more important, inferior STE, particularly when isolated, results from AMI in most instances [34]. Again, the most commonly encountered non-infarction causes of STE usually have electrocardiographically widespread or diffuse STE [23,35,36]. Isolated STE is a rare finding in BER [35], whereas isolated STE is not found in LVH and BBB presentations [23,35].

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Benign early repolarization: Electrocardiographic manifestations and differentiation from other ST segment elevation syndromes

Abstract

Emerg Med Clin North Am

Ann Emerg Med

Am J Cardiol

Ann Emerg Med

Am J Cardiol

Am Heart J

Am J Cardiol

Am J Med Sci

J Emerg Med

Am J Cardiol

Am Heart J

Use of cardiac enzymes identifies patients with acute myocardial infarction otherwise unrecognized in the emergency department

Ann Emerg Med

A prospective evaluation of prehospital 12-lead ECG application in chest pain patients

J Electrocardiol

Selection of patients with acute myocardial infarction for thrombolytic therapy

Ann Intern Med