Early Repolarisation Changes in ECG: Are they Benign or Malignant?

Till recently, ST segment elevation in the absence of conduction abnormalities or chest pain occurring particularly in young bradycardia individuals has been considered a normal variant called early repolarisation (ER). However, recent studies suggest a more worrisome picture as patients with history of idiopathic ventricular fibrillation showed increased prevalence of ER in ECG. ER is an ECG pattern characterised by elevation of the QRS-ST junction (J point) ≥ 2 mv from baseline in the inferior (II, III, aVF) or lateral (I, aVL, V4-V6) leads manifested as QRS slurring or notching. The ER pattern describes the patient with appropriate ECG findings in the absence of symptomatic arrhythmias. The Early Repolarisation Syndrome (ERPS) applies to the patient with both appropriate ECG findings and symptomatic arrhythmias. The current experimental data support the concept that J-point elevation is a marker of increased transmural heterogeneity of ventricular .repolarisation, which increases the vulnerability to ventricular tachyarrhythmias. Male gender, history of syncope or sudden cardiac death (SCD) in family, ER in inferior leads or global ER pattern, terminal notching of QRS complex, J wave amplitude of more than 0.2 mv, horizontal or downward direction of ST segment elevation signify higher risk features for SCD in ER patients. Patients with ER pattern on ECG should have complete cardiac evaluation. The management options for ERPS include anti arrhythmic drugs, implantable cardioverter-defibrillator (ICD) and radiofrequency ablation. There is a need for the physicians to be aware of this entity, hitherto considered as variant of normal ECG pattern especially in young adults and understand its implications, identify high risk subsets and manage with appropriate strategy.