Figure 5.1.1
Discussion
The ECG shows a pattern of early repolarization (ER) in the inferolateral leads, which is associated with a higher risk of cardiac arrest. The current classification of early repolarization patterns on the ECG is as follows:
• Type 1 is associated with ER in the lateral precordial leads. This form is common among healthy male athletes and is thought to be largely benign.
• Type 2 is associated with ER in the inferior or inferolateral leads and is associated with a moderate level of risk.
• Type 3 is associated with ER globally in the inferior, lateral, and right precordial leads, and appears to be associated with the highest relative risk, though the absolute risk of sudden death remains small.
• Type 4, or Brugada syndrome, is marked by J-wave/point elevation in the right precordial leads.
Majid Haghjoo, MD | CASE 5.2 |
Patient History
An asymptomatic 25-year-old male athlete was referred for electrophysiologic evaluation. He had no history of sudden cardiac death in his family. The following ECG was recorded.
Figure 5.2.1 Benign early repolarization ECG pattern. Note the prominent J waves, especially leads V4–V6, rapidly ascending ST-segment elevations, and slurring (blue arrows).
Discussion
Early repolarization (ER) has long been considered as a benign electrocardiographic phenomenon. The first example of malignant variant of ER was reported 15 years ago.1 It has been demonstrated that prognosis of a J wave with a rapidly ascending pattern is similar to persons without ER, whereas horizontal pattern and presence of ER in inferior leads is associated with increased arrhythmic risk.2
References
1. Kalla H, Yan GX, Marinchak R. Ventricular fibrillation in a patient with prominent J (Osborn) waves and ST segment elevation in the inferior electrocardiographic leads: A Brugada syndrome variant? J. Cardiovasc. Electrophysiol. 2000;11:95–98.
2. Tikkanen JT, Junttila MJ, Anttonen O, et al. Early repolarization: Electrocardiographic phenotypes associated with favorable long-term outcome. Circulation. 2011;123:2666–2673.
Juhani Junttila, MD, PhD Tuomas Kenttä, PhD Heikki V. Huikuri, MD, PhD | CASE 5.3 |
Patient History
A previously healthy, 21-year-old male college athlete went through routine preparticipation screening with 12-lead ECG (Figure 5.3.1). He had no history of palpitations or syncope and there was no history of sudden cardiac death in the family.
Figure 5.3.1
Question
Does the young athlete have an increased risk for sudden death according to the ECG?
Answer
According to current knowledge, it seems highly unlikely that the lateral ER pattern with rapidly ascending ST segment presented in the ECG of our patient would increase his risk for sudden cardiac death.
Discussion
Inferolateral early repolarization (ER) is very prevalent among young athletes, especially among African-American athletes. The prevalence of inferolateral ER among college athletes is 30% according to a study by the University of Miami. A majority of ER (~90%) is accompanied by rapidly ascending ST segment after the J-point elevation. This pattern is associated with a benign outcome in middle-aged individuals and can be also considered benign in asymptomatic young athletes.
References
1. Junttila MJ, Sager SJ, Freiser M, et al. Inferolateral early repolarization in athletes. J. Interv. Card. Electrophysiol. 2011;31:33–38.
2. Tikkanen JT, Junttila MJ, Anttonen O, et al. Early repolarization: Electrocardiographic phenotypes associated with favorable long-term outcome. Circulation. 2011;123:2666–2673.
Juhani Junttila, MD, PhD Tuomas Kenttä, PhD Heikki V. Huikuri, MD, PhD | CASE 5.4 |
Patient History
A 45-year-old male comes to a routine exam. He is asymptomatic. He is a current smoker, has a history of hypertension, and his cholesterol levels are elevated. He has a family history of coronary disease. His 12-lead ECG is presented below (Figure 5.4.1).
Figure 5.4.1
Questions
1. Are there any additional risk markers of cardiac death and sudden cardiac death?
2. What would you do in regards of treatment?
Answer
There is an inferior ER pattern with horizontal ST segment in the 12-lead ECG. The pattern is associated with increased risk for sudden cardiac death during a coronary event.
Naturally, the cardiovascular risk factors should be treated as well as possible. Hypertension and hypercholesterolemia should be treated with medication. Additionally, the patient should stop smoking. An exercise ECG test would be a sensible next step in order to find asymptomatic ischemia.
Discussion
Inferolateral early repolarization (ER), especially with horizontal/descending ST segment, has been associated with increased risk for cardiac and arrhythmic death in the general population. In a general population study, the incidence of sudden arrhythmic deaths increased among ER subjects at the age of 55–65 years, which is also the age when first coronary events usually occur. Other studies have also shown the association of inferolateral ER and sudden death due to coronary event.
References
1. Tikkanen JT, Anttonen O, Junttila MJ, et al. Long-term outcome associated with early repolarization on electrocardiography. N. Engl. J. Med. 2009;361:2529–2537.
2. Tikkanen JT, Junttila MJ, Anttonen O, et al. Early repolarization: Electrocardiographic phenotypes associated with favorable long-term outcome. Circulation. 2011;123:2666–2673.
3. Tikkanen JT, Wichmann V, Junttila MJ, et al. Association of early repolarization and sudden cardiac death during an acute coronary event. Circ. Arrhythm Electrophysiol. 2012;5:714–718.
Juhani Junttila, MD, PhD Tuomas Kenttä, PhD Heikki V. Huikuri, MD, PhD |
