Epidemiology

  ER is observed in approximately 1-9% of the general population.

  ER is observed in
15-70% of the cases with idiopathic ventricular fibrillation (VF).

  ER is 3 times more frequent in men.

  ER is more frequently observed in blacks.

  More than
90% of well-trained athletes have ER.



Diagnostic criteria

 
1. At least 2 contiguous leads must show upwardly concave ST segment elevation .

  2.
J wave (notching or slurring of the QRS complex) may accompany (71%).

  3.
Prominent T waves may accompany.



Clinical significance

  ER may involve different leads.

  Localization of the ER has been reported to affect prognosis.

  In asymptomatic individuals observation of ER in
mid-precordial leads (V2, V3, V4) has been reported

     
NOT to increase the arrhythmic risk. Well-trained athletes frequently have this type of ER.

  Observation of
> 0.2mV (> 2mm on standard ECG) ST elevation in inferior leads has been reported to

     
increase the risk of sudden cardiac death 3 times.

  Observation of ER in
inferior and lateral leads show even more risk of sudden cardiac death.

  Elevation of J point amplitude is freqently observed before attacks of VF.




Lability of ER

  Heart rate and vagal tone affects ER.

  In the presence of increased vagal tone or decreased heart rate (after meals or during sleep)

      the risk of ER-related idiopathic VF may increase.

  The ER pattern may decrease or even disappear during adrenergic stimulation (exercise).

      Exercise may also decrease the risk of arrhythmia.



Common aspects of ER and Brugada Syndrome

  More frequently observed in males.

  ST elevation and J wave are observed.

  Arrhythmic events

                  o       frequently occur in ages of 35-45 years.

                  o       frequently occur during bradycardia.

                  o       decrease by Quinidine or Isoproterenol.




References

  N Engl J Med 2009;361:2529-37.

  N Engl J Med 2008;358:2078-9.

  N Engl J Med 2008;358:2016-23.

  J Am Coll Cardiol 2010;56:1177-86.

  Journal of Electrocardiology 2012;45:404-410.





ECG 1. ER in an apparently healthy 39 years-old man. ER is more frequently observed in midprecordial leads (C3 and C4).
In ER, two aspects of ST elevation differentiate it from the ST elevation of myocardial infarction: In ER,
J point is elevated and
the ST segment is upwardly concave
.

The observation of ER
in MID PRECORDIAL leads (V2, V3, V4) is generally regarded as having a benign prognosis.

J point : The point where S wave meets the ST segment.


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ECG 2. The ECG above belongs to a 19 years-old apparently healthy man. The
J waves in V4, V5 and V6 suggest ER.

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ECG 3. The ECG above belongs to a 48 years-old man.
ST elevation in anterior leads and prominent T waves are seen.
The absence of PR segment elevation/depression rules out the diagnosis of pericarditis.


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ECG 4. The ECG above belongs to a 69 years-old man with normal coronary arteries. The
J wave is best seen in lead C3.
The leads C2, C3 and C4 show prominent T waves.


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ECG 5. The ECG above belongs to a 23 years-old man with no known disease. The
J wave is best observed in lead C4. Leads II
and aVF also have upwardly concave ST segment elevation. There is no PR segment elevation or depression to suggest
pericarditis.


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ECG 6. The ECG above belongs to an apparently healthy 20 years-old man. Inferior leads show
J wave and ST segment
elevation. If ER is localized to inferior or inferior + lateral leads and there is accompanying ST segment elevation > 2mm,
the risk of sudden cardiac death increases 3-fold. ER may become more prominent during bradycardia.


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ECG 7. The ECG above belongs to a 35 years-old showing
J wave , ST segment elevation and prominent T waves in
mid-precordial leads. This pattern of ER
DOES NOT INCREASE the risk of sudden cardiac death.

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ECG 8a. The Holter tracing above show how labile ER is. At 00:06
when heart rate increases up to 80s ER pattern almost
disappears
. At 02:34, when heart rate decreses down to 50s ER pattern becomes more clear .

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ECG 8b. The same patient's Holter tracing, 2-3 minutes later.
When heart rate decreses down to 50s the ER pattern becomes
obvious
, when heart rate increases up to 80s the ER pattern almost disappears .

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ECG 9a. The ECG above belongs to a 57 years-old man who does not have any significant coronary artery disease.
The inferior leads show
J waves : early repolarization.

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ECG 9b.
J waves of the same patient.