The Journal of Emergency Medicine, Vol. 17, No. 3, pp.

473 478, 1999 Copyright 1999 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/99 $see front matter

PII S0736-4679(99)00010-4

Selected Topics: Cardiology Commentary

ELECTROCARDIOGRAPHIC MANIFESTATIONS: BENIGN EARLY REPOLARIZATION

William J. Brady,
MD*

and Theodore C. Chan,

MD

*Departments of Emergency Medicine & Internal Medicine, University of Virginia School of Medicine, Charlottesville, Virginia; and Department of Emergency Medicine, University of California San Diego Medical Center, San Diego, California Reprint Address: William Brady, MD, Department of Emergency Medicine, Box 52321, University of Virginia Health Sciences Center, Charlottesville, VA 22906-0114

e AbstractEarly 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 (STE). The electrocardiogram (EKG) ndings of BER include 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 the electrocardiographic ndings useful in making the diagnosis as well as distinguishing BER from other STE syndromes. 1999 Elsevier Science Inc. e Keywords benign early repolarization; early repolarization; normal variant; ST segment; ST segment elevation; electrocardiogram

INTRODUCTION The evaluation and treatment of chest pain patients in the Emergency Department (ED) has undergone tremendous change in the past decade. The benets of early diagnosis and rapid revascularization in the setting of acute myocardial infarction (AMI) are now widely recognized, and have placed greater emphasis on the role of emergency

physicians (EPs) and their competence and ability to interpret electrocardiograms (EKGs) in a rapid manner (1). An ST segment elevation (STE) can indicate an acute coronary ischemic event and remains an important criterion for the initiation of revascularization therapy, including thrombolysis or primary angioplasty (2). However, STE is not a sensitive marker of AMI (3). Other non-infarction syndromes that cause STE on the EKG include left bundle branch block (LBBB), left ventricular hypertrophy (LVH), and left ventricular aneurysm (LVA). These syndromes occur with increased frequency in patients with known coronary artery disease and may confound the ED evaluation of acute ischemia. Other patterns, such as benign early repolarization (BER) and acute pericarditis (AP), are not necessarily associated with ischemic heart disease, though they may resemble acute infarction ST segment waveforms. In one setting, STE was encountered in 22% of all patients presenting to the ED with chest pain. AMI was infrequently the cause of STE and was the nal hospital diagnosis in only 15% of this population. BER was encountered almost as often as AMI (13%) (4). Miller et al. report that of patients admitted to the coronary intensive care unit with presumed AMI, STE was ultimately diagnostic for acute infarct in only half with a past history of ischemic heart disease (5). These STE syndromes can be misdiagnosed

Selected Topics: Cardiology Commentary is coordinated by Theodore Chan, Diego Medical Center, San Diego, California

MD,

of the University of California San

RECEIVED: 13 November 1998; ACCEPTED: 30 November 1998

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Figure 1. 12-lead EKG revealing normal sinus rhythm with widespread STE. The STE was noted in the anterior (V2-V4), lateral (V5 and V6), and inferior (II, III, aVf) leads. The STE is characterized by initial concavity in all leads. Prominent T waves were also encountered across the precordium. J point irregularity was seen in the inferior distribution. No ST segment depression (reciprocal change) was noted. The electrocardiographic ndings were felt to represent BER.

as acute infarction that then may subject the patient to unnecessary, potentially dangerous therapies and procedures. Sharkey et al. report that 11% of patients receiving a thrombolytic agent were not in fact experiencing AMI. BER was the cause of the electrocardiographic ndings in 30% of these cases (6). The following discussion focuses on BER as a cause of non-ischemic ST segment elevation, and includes the electrocardiographic changes useful in making this diagnosis as well as distinguishing BER from other syndromes.

Case Two A 35-year-old female presented to the ED via ambulance with dyspnea and substernal chest pain. She had recently used cocaine. The examination revealed the patient to be in distress, clutching her chest; the remainder of the examination was otherwise unremarkable. A 12-lead EKG (Figure 3) demonstrated sinus rhythm with STE. The patient received sublingual nitroglycerin and i.v. lorazepam with resolution of the discomfort. Serial EKGs that were performed did not reveal change. She was admitted to the chest pain center with a R/O MI protocol. No further pain was noted; the serial enzymes and EKGs did not demonstrate ischemia or infarction the EKGs were felt to represent BER. The patient was discharged from the ED against medical advice before performance of the stress test.

CASE PRESENTATIONS Case One A 41-year-old male without past medical history presented to the ED with chest pain. The pain had appeared approximately 5 days before; it worsened upon inspiration and with upper extremity movement and had no associated symptoms. The physical examination was normal; no chest wall tenderness was found. A 12-lead EKG (Figure 1) revealed normal sinus rhythm with widespread STE, which was felt to be consistent with BER. The patient was admitted to the ED-based chest pain center and underwent rule-out myocardial infarction (R/O MI) with serial cardiac enzyme and EKG analyses that did not reveal myocardial infarction; the repeat EKGs did not demonstrate change (Figure 2; lead II is shown from sequential EKGs obtained approximately every 10 min). Further, an EKG obtained 2 years prior during a routine examination revealed similar ndings. The patient underwent a stress test that was normal; he was discharged with a diagnosis of chest pain of unclear etiology.

DISCUSSION The syndrome of benign early repolarization, rst described in 1936 by Shipley and Hallaran, is felt to be a normal variant, not indicative of underlying cardiac

Figure 2. Lead II is shown, obtained from sequential EKGs performed approximately every 10 min in the patient from Case One. Initially, with ongoing pain, no evolution of the STE was seen. With resolution of the discomfort, the EKG remained unchanged, once again suggesting that the STE resulted from BER and not from AMI.

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Figure 3. 12-lead EKG demonstrating sinus rhythm with STE in inferior (II, III, aVf) and anterolateral (V2 through V6) leads as well as notching of the J point and prominent T waves. The leads with STE all demonstrate a concavity to the initial, upsloping portion of the ST segment/T wave complex. The EKG suggests BER. Serial EKGs did not reveal evolution of the STE; comparison with a past EKG revealed similar ST segment waveforms.

disease (7). 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 symmetric, concordant T waves of large amplitude (8). The electrocardiographic definition of BER (Figure 4 and Table 1) includes the following characteristics: ST segment elevation; upward concavity of the initial portion of the ST segment; notching or slurring of the terminal QRS complex; symmetric, concordant T waves of large amplitude; widespread or diffuse distribution of ST segment elevation on the EKG; and relative temporal stability (8). BER has been reported to occur in approximately 1% of the general population, in persons of all age groups and varying racial and ethnic backgrounds (9). Young military recruits demonstrate BER in 1 to 2% of individuals, and it is also common in athletes (10,11). Among adult ED chest pain patients, BER is seen at an increased frequency and is encountered in 13% of such cases (4). Hollander et al. report nding BER in 23 to 48% of adult ED chest pain patients who use cocaine (12). In a large population-based study, the mean age of patients with BER was 39 years with a range of 16 to 80 years. BER is seen predominantly in patients less than age 50 and rarely in individuals over age 70 (3.5%) (9). Men manifest BER signicantly more often than women (9). For unknown reasons, BER is more often encountered in black men age 20 to 40 years (13), though some dispute this nding (9).

ST Segment Elevation The ST segment elevation begins at the J (or junction) point of the QRS complex and ST segment. The degree of STE encountered in BER is usually less than 2 mm but

Figure 4. Representative example of electrocardiographic complex depicting BER. The complex demonstrates STE with elevation of the J point. The initial portion of the ST segment/T wave complex is concave. The ST segments of BER appear to have been lifted evenly off the baseline, thereby preserving the normal upward concavity of the J point.

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Table 1. Electrocardiographic Criteria Suggestive of Benign Early Repolarization Widespread ST segment elevation (precordial leads limb leads) J point elevation Concavity of initial upsloping portion of ST segment Notching or irregular contour of J point Prominent, concordant T waves (large amplitude) Relatively xed/constant pattern Reduction in ST segment elevation with sympathomimetic factors

W. J. Brady and T. C. Chan

may approach 5 mm in certain individuals. Eighty to ninety percent of individuals demonstrate STE less than 2 mm in the precordial leads and less than 0.5 mm in the limb leads; only 2% of cases of BER manifest STE greater than 5 mm (9,14). See Figures 4 and 5 for examples of the STE seen in the BER patient.

ST Segment Morphology In BER, the ST segment looks as if it has been lifted upward evenly from the isoelectric baseline at the J point, preserving the normal concavity of the initial, upsloping portion of the ST segmentT wave complex (8). This STE morphology is a very important feature that distinguishes BER-related ST segment elevation from that associated with AMI (Figures 4 and 5). The J point itself is frequently notched or irregular in contour and is considered highly suggestive, but not diagnostic, of BER (Figure 5, upper panel) (8,9,15). The degree of J point elevation is usually less than 3.5 mm (9).

T Wave Findings Prominent T waves of large amplitude and slightly asymmetric morphology are also encountered; the T waves may appear peaked, suggestive of the hyperacute T wave encountered in AMI. The prominent T waves are concordant with the QRS complex and are usually found in the precordial leads (Figures 3 and 5). The height of the T waves in BER ranges from approximately 6.5 mm in the precordial distribution to 5 mm in the limb leads (8,9,13,16).

Figure 5. Representative examples of electrocardiographic complexes depicting BER. Upper panel: Single electrocardiographic complex demonstrating BER and three characteristic features including J point elevation, notching of the J point, and concavity of the initial, upsloping portion of the ST segment. Middle panel: Two electrocardiographic complexes demonstrating BER in the limb leads (lead II) and the characteristic concavity of the initial portion of the ST segment. Lower panel: Precordial lead with pronounced STE with initial concavity of the ST segment and prominent T waves.

Distribution The degree of STE in BER is usually greatest in the midto left precordial leads (leads V2 to V5), and less often found in the limb leads. One large series reported that the

limb leads reveal STE in only 45% of cases of BER. Lead aVr does not demonstrate STE due to BER (14). Isolated BER in the limb leads (no STE in the precordial leads) is a very rare nding (9,14). Such isolated STE in the inferior (II, III, and aVf) or lateral (I and aVl)

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leads should prompt consideration of another explanation for STE.

Temporal Stability Lastly, the chronic nature of STE helps in the diagnosis of BER, as patients tend to demonstrate this EKG pattern consistently over time. However, certain patients may demonstrate transient uctuations and changes in the degree of STE. The magnitude of BER may also lessen over time as the patient ages. In 25 to 30% of patients with BER previously documented on EKG, a repeat EKG many years later will reveal complete disappearance of the pattern (9,14). The use of serial EKGs and ST segment trend monitoring will demonstrate stable ST segments in the patient with BER (Figure 2). The patient with AMI will most often reveal dynamic ST segment change in the early ED evaluation.

Figure 6. Electrocardiographic complex of a patient with acute pericarditis. Note the concave nature of the STE as well as PR segment depression.

Electrocardiographic Differential Diagnosis The electrocardiographic differential diagnosis of STE not only includes the benign variant BER but also potentially more-malignant syndromes including LBBB, LVH, LV aneurysm, acute pericarditis, and AMI. LBBB and other intraventricular conduction abnormalities manifest with a prolonged QRS duration. LVH is suggested by the pattern of EKG forces (i.e., large Q and R in leads V1 and V6, respectively). Clinically, left ventricular aneurysm is unlikely in patients without a history of AMI. Acute pericarditis and BER are often difcult to distinguish on the EKG. The STE encountered in the two syndromes is similar, both demonstrating an initial concavity of the upsloping ST segmentT wave complex. In acute pericarditis, however, the PR segment is often depressed, particularly in lead V6 (and can be elevated in lead aVr in such instances), whereas the PR is usually normal in BER (16,17). See Figure 6 for a representative example of an electrocardiographic complex with acute pericarditis. The EKG changes associated with early pericarditis, particularly STE, evolve in most cases over several hours to days, while in BER, they remain constant (18). The STE in pericarditis tends to be more widespread across the EKG in both precordial and limb leads, though isolated pericarditis does occur (16,18,19). Unlike BER, the T wave in pericarditis is frequently normal in amplitude and morphology. The ratio of the ST segment elevation to the height of the T wave (ST/T) is also a helpful guide. A ratio greater than 0.25 in lead V6 strongly suggests pericarditis (19). The distinction of STE in BER vs. AMI is made using several EKG criteria, including an analysis of ST seg-

mentT wave complex waveform, presence of reciprocal change, and evolutionary changes. This distinction can be difcult. Sharkey et al. report that approximately 30% of patients who incorrectly receive thrombolytic therapy for presumed AMI actually have BER (6). The initial, upsloping portion of the ST segmentT wave complex is concave in BER compared with either attened or convex in AMI, though it is important to note that STE in AMI may demonstrate transient concavity (16). Reciprocal change, dened as ST segment depression in leads distant from the area of acute infarction, is a very useful EKG nding in acute ischemia (20) not found in BER. Furthermore, ST segment depression greater than 1 mm in a patient with STE should suggest the possibility of AMI (17). The combined ndings of ST segment elevation greater than 1 mm in two anatomically contiguous leads and reciprocal ST segment depression increase the diagnostic accuracy for ischemia to over 90% (20). The addition of Q waves with reciprocal change and STE also strongly suggests the possibility of AMI (17). Lastly, the performance of serial EKGs may demonstrate dynamic electrocardiographic changes that occur in acute ischemia and not BER (16).

CONCLUSION Benign early repolarization is a normal electrocardiographic variant not indicative of underlying cardiac disease found in approximately 1% of the general population and in up to 48% of chest pain patients in the ED. Findings of BER include diffuse or widespread ST segment elevation, upward concavity of the initial portion of the ST segment, notching or slurring of the terminal QRS

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8. Wasserburger RM, Alt WJ, Lloyd C. The normal RS-T segment elevation variant. Am J Cardiol 1961;8:184 92. 9. Mehta MC, Jain AC. Early repolarization on scalar electrocardiogram. Am J Med Sci 1995;309:30511. 10. Parisi A, Beckmann C, Lancaster M. The spectrum of ST segment elevation in the electrocardiograms of healthy adult men. J Electrocardiol 1971;4:136 44. 11. Hanne-Paparo N, Drory Y, Schoenfeld Y. Common EKG changes in athletes. Cardiology 1976;61:26778. 12. Hollander JE, Lozano M, Fairweather P, et al. Abnormal electrocardiograms in patients with cocaine-associated chest pain are due to normal variants. J Emerg Med 1994;12:199 205. 13. Thomas J, Harris E, Lassiter G. Observations on the T wave and S-T segment changes in the precordial electrocardiogram of 320 young negro adults. Am J Cardiol 1960;5:468 74. 14. Kabara H, Phillips J. Long-term evaluation of early repolarization syndrome (normal variant RS-T segment elevation). Am J Cardiol 1976;38:157 61. 15. Golderger AL. Myocardial infarction: electrocardiographic differential diagnosis, ed 4. St. Louis: Mosby; 1991:100 26. 16. Aufderheide TP, Brady WJ. Electrocardiography in the patient with myocardial ischemia or infarction. In: Gibler WB, Aufderheide TP, eds. Emergency cardiac care, ed 1. St. Louis: Mosby; 1994:169 216. 17. Spodick DH. Differential diagnosis of the electrocardiogram in early repolarization and acute pericarditis. N Engl J Med 1976; 295:523 6. 18. Mabeyt BE, Walls RM. Acute pericarditis. J Emerg Med 1985;3: 457 67. 19. Glinzton LE, Laks MM. The differential diagnosis of acute pericarditis from the normal variant: new electrocardiographic criteria. Circulation 1982;65:1004 9. 20. Otto LA, Aufderheide TP. Evaluation of ST segment elevation criteria for the prehospital electrocardiographic diagnosis of acute myocardial infarction. Ann Emerg Med 1994;23:1724.

complex, and symmetric, concordant T waves of large amplitude. It is important to distinguish BER from more serious causes of STE, including LBBB, LVH, LV aneurysm, pericarditis, and AMI.

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