41 y.o male with no significant PMH, presents with 2-3 months of intermittent, non-exertional chest pain, lasting a few seconds. No other associated symptoms.
BP 126/83, HR 63, RR 16, Temp 97.8, O2Sat 100%
What is your impression of the EKG?
ST elevation in leads V1-V6, II, III, AVF J point elevation with notching (look at V4) Concavity to ST segments
+ Key features
Widespread concave ST elevation <2mm data-preserve-html-node="true"
J-point elevation with notching (often best seen in V4)
Prominent T waves that are concordant (point in same direction) as QRS complex
Normal R wave progression
No reciprocal changes
Stable appearance on serial EKG
+ Why is this important?
Early Repolarization is a common EKG pattern to recognize, seen in young (< 50 y.o), healthy people. It can mimic pericarditis or acute MI. Be careful of diagnosing early repol in pts over 50 as ST elevation is more commonly due to acute MI. Also remember when calculating a pt's HEART score early repolarization counts as an EKG abnormality!
Is early repolarization truly benign? – A 2009 cohort study showed increased risk of death from cardiac causes in pts with early repolarization in inferior leads (Tikkanen et al, NEJM). Another study showed that in pts with idiopathic V fib there was an increased prevalence of early repolarization (Haissaguerre et al, NEJM)
Dr Smith’s blog on Early repol vs ischemia - http://hqmeded-ecg.blogspot.com/search/label/early%20repolarization
Tikkanen et al - http://www.nejm.org/doi/full/10.1056/NEJMoa0907589#t=articleMethods
Haissaguerre et al - http://www.nejm.org/doi/full/10.1056/NEJMoa071968#t=abstract