Risk stratification of ventricular fibrillation in patients with symptomatic Brugada syndrome using pharmacological tests.

BACKGROUND: Brugada syndrome (BrS), which is characterized by J-point elevation in right precordial leads of a 12-lead electrocardiogram, is associated with the occurrence of ventricular fibrillation (VF). However, risk stratification of VF in patients with BrS remains challenging. OBJECTIVE: The aim of this study was to identify a risk predictor of VF in patients with BrS using pharmacological tests. METHODS: Twenty-one consecutive patients with BrS and a history of documented spontaneous VF (n = 16) or syncope presumed to be caused by lethal ventricular arrhythmia (n = 5) were enrolled. J-wave changes in response to intravenous verapamil, propranolol, and pilsicainide were separately assessed. RESULTS: During the median follow-up period of 86.0 months, 8 patients had VF recurrence (recurrence group) and 13 patients did not have VF recurrence (non-recurrence group). Intravenous propranolol injection induced significant J-wave augmentation (i.e., increase in amplitude >0.1 mV) in the inferior and/or lateral leads in the recurrence group compared to the non-recurrence group (p = .048 and p = .015, respectively). Kaplan-Meier analysis revealed that VF recurrence is significantly higher in patients with BrS and J-wave augmentation due to intravenous propranolol than in patients without J-wave augmentation (p = .014). CONCLUSION: The study results show that propranolol-induced J-wave augmentation is involved in the risk of VF in patients with BrS. The results suggest that early repolarization patterns in response to pharmacological tests may be useful for risk stratification of VF in patients with symptomatic BrS.

Early repolarization pattern on ECG predicts worse outcomes in patients hospitalized due to chronic heart failure decompensation.

BACKGROUND: To improve the outcomes of patients with chronic heart failure (CHF), it is important to identify reliable prognostic tools. Early repolarization pattern (ER) on 12­lead electrocardiogram (ECG) is a predictor of worse outcomes, which has been widely researched in the general population but not in the CHF population. OBJECTIVE: To evaluate the incidence and prognostic value of ER and compare its prognostic significance with other non-invasive diagnostic methods for CHF outcomes and hospital readmissions. METHODS: The study included 301 patients (166 men and 135 women) hospitalized for CHF decompensation. CHF diagnosis was confirmed according to the current guidelines. The patients underwent standard tests and impedance cardiography (ICG) at enrollment and on the day of discharge. RESULTS: Thirty-one confirmed ER cases (10.3%) were enrolled. During a median follow-up period of 18 months, 128 cardiac-related deaths were observed (42.5%), with 23 (74.2%) and 105 (38.9%) patients in the ER and non-ER groups, respectively (p < 0.001). The ER group had more readmissions than the non-ER group did at 6-months (2 [1, 2] vs. 1 [1, 2]; p=0.04) and 12-months (3 [2-4] vs. 2 [1-3]; p<0.001). ER on ECG (hazard ratio [HR] 2.59; 95% confidence interval [CI] 1.64-4.07; p<0.001), N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels ≥425.5 pmoL/L (HR 5.1; 95% CI 3.33-7.83; p < 0.001), thoracic fluid content (TFC) ≥36.9 1/kΩ (HR 4.6; 95% CI 2.7-7.85, p < 0.001), and left ventricular ejection fraction (LVEF) ≤40% (HR 4.94; 95% CI 2.83-8.65; p < 0.001) were independently and significantly associated with cardiac death. CONCLUSIONS: The combination of ER, LVEF ≤40%, NT-proBNP, or TFC provides an incremental prognostic value for cardiac-related death in patients with CHF.

Electrocardiographic Changes Associated with Early Repolarization Pattern in Healthy Young Males.

Background and Objectives: Early repolarization pattern (ERP) has recently been shown to be related with an increased risk of ventricular arrhythmias in susceptible individuals. Materials and Methods: We studied the ERP-associated ECG changes, with potential clinical relevance, in 220 young (age 22.1 ± 1.6 years), healthy, male subjects using 12-lead ECG recordings. A total of 38 subjects (17.3%) fulfilled the diagnostic criteria for ERP, and a total of 90 ECG characteristics were compared between the groups of subjects with and without ERP. Results: None of the ECGs were pathological, and 22 ECG parameters differed significantly (p < 0.05) between the subjects with and without ERP. Among them, the P wave-related parameters (e.g., average P wave duration: 101.5 ± 9.2 ms vs. 106.8 ± 9.9 ms, p = 0.004) and the presence of fragmented QRS complexes (67.6% vs. 92.1%, p = 0.002) revealed a potential propensity for atrial and ventricular arrhythmogenesis. The time-domain parameters of repolarization, those not corrected for QRS duration, showed shorter values (e.g., Tpeak-Tend interval: 70.9 ± 8.1 ms vs. 67.8 ± 8.0 ms, p = 0.036), reflecting the accelerated repolarization. Conclusions: Certain ECG characteristics seem to be more associated with ERP. The clinical significance of this finding at the individual level needs further prospective investigations.

Evaluation of Atrial Electromechanical Delay and Left Atrial Phasic Function in Individuals with Electrocardiographic Early Repolarization Pattern.

Background: Atrial electromechanical delay (EMD) and left atrial (LA) phasic function have been demonstrated to be predictors for the development of atrial fibrillation (AF). In the present study, we aimed to evaluate atrial EMD and LA phasic function in individuals with electrocardiographic early repolarization pattern (ERP). Methods: Eighty consecutive individuals with ERP and 40 age- and gender-matched control subjects without ERP were compared in this cross-sectional study. Atrial electromechanical coupling (Pa') was measured from lateral mitral annulus (Pa'lateral), septal mitral annulus (Pa'septal), and lateral tricuspid annulus (Pa'tricuspid) using tissue Doppler echocardiography to calculate intra- and inter-atrial EMD. LA maximal volume, LA minimal volume, and LA volume before atrial contraction were calculated using the biplane area-length method to assess LA phasic function. Results: LA diameter, LA volume index, Pa'lateral, Pa'septal, Pa'tricuspid electrical activity and intra-left atrial EMD were significantly increased in the ERP patients. Mitral lateral, septal, tricuspid lateral annular tissue Doppler s' and e' waves were significantly decreased in the ERP patients. There were no significant difference between the groups in terms of interatrial EMD, intra-right atrial EMD, LA total emptying volume and LA total emptying fraction indicating LA reservoir function, LA passive emptying volume and LA passive emptying fraction indicating LA conduit function, LA active emptying volume and LA active emptying fraction indicating LA pump function. Conclusions: Left atrial EMD parameters are affected in individuals with ERP, but LA phasic functions are not affected. Further prospective studies are needed to clarify whether individuals with ERP have an increased susceptibility to AF.

Early repolarization pattern in adult females with eating disorders.

INTRODUCTION: The risk of cardiovascular death is increased in patients with eating disorders (ED), but the background for this is unknown. Early repolarization pattern (ERP) on the electrocardiogram (ECG) has been associated with increased risk of sudden cardiac death. METHODS: We investigated the prevalence of ERP in 233 female patients with anorexia nervosa (AN) and bulimia nervosa (BN) (age 18-35 years) compared with 123 healthy female controls. RESULTS: Early repolarization pattern was present in 52 (22%) of ED patients (16 (15%) AN patients and 36 (29%) BN patients) and 17 (14%) of healthy controls. When adjusting for age, BMI, heart rate, use of selective serotonin reuptake inhibitors (SSRI), and potassium level, the odds ratio (OR) for ERP was 2.1 (95% CI 1.1-4.2, p = .03). There was an increased prevalence of inferolateral ERP in patients with ED compared with healthy controls (OR = 4.3, 95% CI 1.7-11.3, p = .003) as well as ERP with a downward/horizontal sloping ST segment (OR = 3.1, 95% CI 1.3-7.6, p = .01). Additionally, J-point elevation >0.2 mV was more prevalent in patients with ED (OR = 3.3, 95% CI 1.1-9.7, p = .03). CONCLUSION: The prevalence of ERP was increased in patients with ED compared with healthy controls. This finding may provide a possible explanation for the increased cardiovascular mortality in ED patients.

The diagnostic value of 2D-speckle tracking echocardiography for identifying subclinical ventricular dysfunction in subjects with early repolarization pattern.

INTRODUCTION: Early repolarization pattern (ERP) can exist a silent substrate for arrhytmic events in accordance with the previous studies which have shown there has been evidence of morphological changes in left ventricle (LV) in ERP subjects. Despite structural changes in ERP subjects, it has not exactly known whether a change in LV functional parameters occur in ERP. The aim of our study was to investigate LV functional parameters in ERP athletes evaluated by 2D- speckle tracking echocardiography (2D-STE). METHOD: In this study, athletes with ERP (n = 50) and athletes without ERP (n = 50) were recruited between April 2018 and September 2018. For each case, 2D- TTE and 2D- STE evaluation were performed by the same cardiologist. RESULTS: Left ventricle mean global longitudinal strain (GLS) (P < .001) and GLS at all apical chamber views (P < .001), longitudinal peak systolic strain rate (SRS) at A3C (P: .011), early diastolic strain rate (SRE) at A3C (P < .001) and late diastolic strain rate (SRA) at A3C (P: .034) in the ERP athletes were significantly lower than those in the athletes without ERP. LV basal segment circumferential SRS (P: .002) and SRE (P: .006) were significantly lower in ERP athletes compared to athletes without ERP. LV mechanical dispersion was significantly higher in ERP athletes compared to athletes without ERP (P < .001). CONCLUSION: Our study suggests ERP can be more associated with impaired LV longitudinal function than circumferential function. In addition, both LV inferolateral region and basal segment can be more affected functionally in ERP athletes.

Fibrosis and Conduction Abnormalities as Basis for Overlap of Brugada Syndrome and Early Repolarization Syndrome.

Brugada syndrome and early repolarization syndrome are both classified as J-wave syndromes, with a similar mechanism of arrhythmogenesis and with the same basis for genesis of the characteristic electrocardiographic features. The Brugada syndrome is now considered a conduction disorder based on subtle structural abnormalities in the right ventricular outflow tract. Recent evidence suggests structural substrate in patients with the early repolarization syndrome as well. We propose a unifying mechanism based on these structural abnormalities explaining both arrhythmogenesis and the electrocardiographic changes. In addition, we speculate that, with increasing technical advances in imaging techniques and their spatial resolution, these syndromes will be reclassified as structural heart diseases or cardiomyopathies.

Early repolarization pattern associated with coronary artery disease and increased the risk of cardiac death in acute myocardium infarction.

BACKGROUND: Early repolarization pattern (ERP) was associated with sudden cardiac death in recent studies. However, the associations between ERP and coronary artery disease (CAD), and ERP and cardiac death caused by acute myocardial infarction (MI) remains unclear. METHODS: We retrospectively enrolled consecutive 1,545 CAD patients and 908 non-CAD subjects as control group which were confirmed by coronary angiograph. The CAD patients include stable CAD, acute MI patients, and old MI patients. Multivariate logistic regression was employed to evaluate the relationship between ERP and CAD, and ERP and cardiac death caused by acute MI. RESULTS: Of the 1,545 CAD subjects, there were 1,029 stable CAD patients, 404 acute MI patients, and 112 old MI patients. The incidence of ERP was much higher among patients with CAD than without CAD subjects (20.1% vs. 6.2%, p < .001) after adjusting for major cardiovascular risk factors. No significant correlation was observed between lead region of ERP on 12-lead ECG and single abnormal artery. Of the 404 acute MI patients, 342 patients survived and 62 patients died. Incidence of ERP was higher in non-survivor than survivor patients with acute MI (24.2% vs. 17.5%, p = .006) after adjustment for major cardiovascular risk factors. CONCLUSION: The incidence of ERP was higher in CAD patients than subjects without CAD and in non-survivor patients than survivor patients with acute MI. The lead region of ERP on 12-lead ECG was not associated with single abnormal coronary artery.

Identification of malignant early repolarization pattern by late QRS activity in high-resolution magnetocardiography.

BACKGROUND: The early repolarization pattern (ERP) in electrocardiography (ECG) has been considered as a risk for ventricular fibrillation (VF), but effective methods for identification of malignant ERP are still required. We investigated whether high spatiotemporal resolution 64-channel magnetocardiography (MCG) would enable distinction between benign and malignant ERPs. METHODS: Among all 2,636 subjects who received MCG in our facility, we identified 116 subjects (43 ± 18 years old, 54% male) with inferior and/or lateral ERP in ECG and without structural heart disease, including 13 survivors of VF (ERP-VF(+)) and 103 with no history of VF (ERP-VF(-)). We measured the following MCG parameters in a time-domain waveform of relative current magnitude: (a) QRS duration (MCG-QRSD), (b) root-mean-square of the last 40 ms (MCG-RMS40), and (c) low amplitude (<10% of maximal) signal duration (MCG-LAS). RESULTS: Compared to ERP-VF(-), ERP-VF(+) subjects presented a significantly longer MCG-QRS (108 ± 24 vs. 91 ± 23 ms, p = .02) and lower MCG-RMS40 (0.10 ± 0.08 vs. 0.25 ± 0.20, p = .01) but no difference in MCG-LAS (38 ± 22 vs. 29 ± 23 ms, p = .17). MCG-QRSD and MCG-RMS40 showed significantly larger area under the ROC curve compared to J-peak amplitude in ECG (0.72 and 0.71 vs. 0.50; p = .04 and 0.03). The sensitivity, specificity, and odds ratio for identifying VF(+) based on MCG-QRSD ≥ 100 ms and MCG-RMS40 ≤ 0.24 were 69%, 74%, and 6.33 (95% CI, 1.80-22.3), and 92%, 48%, and 10.9 (95% CI, 1.37-86.8), respectively. CONCLUSION: Magnetocardiography is an effective tool to distinguish malignant and benign ERPs.

Early repolarization pattern as a predictor of atrial fibrillation recurrence following radiofrequency pulmonary vein isolation.

BACKGROUND: Early repolarization patterns (ERP) have been found to be associated with poor cardiovascular end points. We aimed to evaluate the ERP prevalence among patients with structurally normal hearts undergoing radiofrequency (RF) pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) ablation and its association with the AF recurrence. METHODS: All consecutive patients who underwent RF-PVI as index procedure for paroxysmal AF in our center were evaluated. EXCLUSION CRITERIA: structural heart disease, ongoing use of Class I/III antiarrhythmics, complete-bundle-branch-block. Lateral (I, aVL, V5 -V6 ), inferior (II, III, aVF), or infero-lateral (both) ERP were defined in baseline ECG as horizontal/downsloping J-point elevation ≥1 mm in two consecutive leads with QRS slurring/notching. Documented episodes of AF lasting ≥30 s were considered recurrence. RESULTS: Of 701 cases, 434 patients (305 males, 58 ± 11 years) were included for analysis. ERP observed in 67 patients (15.4%) (Infero-lateral n = 26, inferior n = 23, lateral n = 18) which were significantly younger, demonstrating longer PR-interval and lower heart rates. At a mean follow-up of 22.1 ± 9.7 months, AF recurrences were found in 107 patients (24.6%). In middle-aged patients (≥40-<60 years; n = 206, 79% male), those with an infero-lateral ERP had higher recurrence compared with the ones without (56.3% vs. 19%; p = 0.002). Infero-lateral ERP was significantly predicting recurrence (HR 2.42, 95% CI 1.21-4.82; p = 0.01). CONCLUSION: Early repolarization patterns was more prevalent in our AF population than in the general population. Infero-lateral ERP in baseline ECG might predict AF recurrence in the follow-up after RF-PVI in middle-aged patients.

The effect of exercise on the ECG criteria for early repolarization pattern.

OBJECTIVE: To determine the effect of exercise and heart rate on the early repolarization (ER) pattern; focusing on the new criteria for identification of ER. METHODS: The ECG measurements on the terminal QRS notch or slur found in early repolarization were quantitated before, during and after exercise; specifically: (i) the amplitude at the onset of the notch (Jo) (ii) the amplitude at the peak of the notch (Jp), (iii) the amplitude at the end of the notch (Jt), (iv) the duration from Jo to Jp (D1) and (v) the duration from Jo to Jt (D2). RESULTS: All individuals (N = 21) fulfilling the criteria for ER showed complete disappearance of ER after 3 min of exercise. After 5 min of recovery, 29% of subjects showed return of the ER. The return of ER was dynamic with QRS notching of varying extent, without ST elevation, being evident first. The relationship between heart rate and ER was significant and nonlinear, best fit by a second-order polynomial, suggesting that changes in heart rate with exercise was a factor influencing the presence of the ER pattern and the parameters that define ER. CONCLUSION: Each of the newly defined characteristics of the ER are modified and eventually disappear with exercise. The return of ER was dynamic with QRS notching of varying extent being evident first. The changes correlated with variations in heart rate, during both exercise and recovery, suggesting, in part, a role in the underlying mechanism of ER.

A Heterozygous Missense hERG Mutation Associated with Early Repolarization Syndrome.

BACKGROUND/AIMS: Early repolarization syndrome (ERS) has been recently recognized as early repolarization pattern with idiopathic ventricular fibrillation. However, the genetic background of ERS has not been fully understood. METHODS: A Chinese family with sudden cardiac death associated with ERS was investigated. Direct sequencing of ERS susceptibility genes was performed on the proband and family members. Whole-cell patch-clamp methods were used to characterize the mutant channel expressed in HEK 293 cells. RESULTS: One missense mutation (p. K801T) was found in the hERG (KCNH2 gene) by the direct sequencing of candidate genes. Whole cell voltage clamp studies of the K801T mutation in HEK 293 cells demonstrated a 1.5-fold increase in maximum steady state current (37.2±7.3 vs 20.3±4.4 pA/pF) that occurred at a 20 mV more positive potential compared to the wild type channels. The voltage dependence of inactivation was significantly shifted in the positive voltage direction (WT -59.5±1.4 vs K801T -44.3±1.2 mV). Kinetic analysis revealed slower inactivation rates of K801T, but faster rates of activation and deactivation. The hERG channel blockers tested inhibited K801T-hERG channel in concentration response, and the potencies of these drugs can be rank-ordered as follows: quinidine> disopyramide> sotalol> flecainide. CONCLUSION: Our study indicated that the K801T mutation caused the gain of function of hERG channels that may account for the clinical phenotype of ERS. Quinidine and disopyramide could improve the function of K801T-hERG mutant channel, and may be therapeutic options for patients with the K801T hERG mutation.

Early Repolarization Pattern Predicts the Increased Risk of Ventricular Arrhythmias in Patients With Acute Anterior ST-Segment Elevation Myocardial Infarction　- A Propensity Analysis.

BACKGROUND: The association between the early repolarization pattern (ERP) and ventricular arrhythmias in patients with ST-segment elevation myocardial infarction (STEMI) remains uncertain. We hypothesized that ERP predicts the risk of sustained ventricular tachycardia (VT)/ventricular fibrillation (VF) during the acute phase of anterior STEMI.Methods and Results:We enrolled 1,460 consecutive patients with acute anterior STEMI. We identified an ERP-positive group and a 1:6 propensity-matched ERP-negative group of 183 and 471, respectively. Comparisons of sustained VT/VF, heart failure, major adverse cardiovascular events and all-cause death were based on Kaplan-Meier survival analysis and multivariable Cox proportional hazards regression with adjustment for unmatched confounding factors. In our full matching propensity score cohorts, there were 8 out of 28 variables not matching between the 2 groups. The Kaplan-Meier curves showed ERP increased the risk of sustained VT/VF in 30 days (log-rank test P=0.00065). Adjusted for baseline unmatched confounding risk, the Cox hazards regression analysis showed sustained VT/VF was associated with the present of ERP (hazard ratio=2.915, 95% CI: 1.520-5.588, P=0.001). CONCLUSIONS: In a propensity score-adjusted cohort the presence of ERP had a multivariable-adjusted association with increased risk of sustained VT/VF in patients with anterior STEMI in the early 30 days.

Early repolarization pattern: a marker of increased risk in patients with catecholaminergic polymorphic ventricular tachycardia.

AIMS: The early repolarization pattern (ERP) has been shown to be associated with arrhythmias in patients with short QT syndrome, Brugada syndrome, and ischaemic heart disease. Catecholaminergic polymorphic ventricular tachycardia (CPVT) is an inherited arrhythmia syndrome and related to malignant ventricular tachyarrhythmias in a structurally normal heart. The aim of this study was to evaluate the prevalence of ERP and clinical events in patients with CPVT. METHODS AND RESULTS: Digitalized resting 12-lead ECGs of patients were analysed for ERP and for repolarization markers (QT and Tpeak-Tend interval). The ERP was diagnosed as 'notching' or 'slurring' at the terminal portion of QRS with ≥0.1 mV elevation in at least two consecutive inferior (II, III, aVF) and/or lateral leads (V4-V6, I, aVL). Among 51 CPVT patients (mean age 36 ± 15 years, 11 males), the ERP was present in 23 (45%): strictly in the inferior leads in 9 (18%) patients, in the lateral leads in 9 (18%) patients, and in infero-lateral leads in 5 (10%) patients. All patients with ERP were symptomatic at presentation (23 of 23 patients with ERP vs. 19 of 28 patients without ERP, P = 0.003). Syncope was also more frequent in patients with ERP (18 of 23 patients with ERP vs. 11 of 28 patients without ERP, P = 0.005). CONCLUSION: A pathologic ERP is present in an unexpected large proportion (45%) of patients and is associated with an increased frequency of syncope. In patients with unexplained syncope and ERP at baseline, exercise testing should be performed to detect CPVT.

Early repolarization pattern is the strongest predictor of arrhythmia recurrence in patients with idiopathic ventricular fibrillation: results from a single centre long-term follow-up over 20 years.

AIMS: Idiopathic ventricular fibrillation (iVF) accounts for up to 14% of VF incidence. Data regarding long-term outcome and clinical risk markers of arrhythmia recurrence are scarce. The objective of our study was to describe a long-term follow-up (FU) of a cohort of iVF survivors in our centre during the past 20 years, and to investigate the influence of clinical parameters, e.g. presence of an early repolarization pattern (ERP), on recurrence rate of arrhythmias. METHODS AND RESULTS: Thirty-five iVF survivors were identified and retrospectively analysed regarding recurrent implantable cardioverter-defibrillator (ICD) interventions and covariates potentially influencing arrhythmia recurrence. Appropriate ICD interventions occurred in 15 patients (43%) after a median of 6.6 years during a median FU period of 8.8 years. Two patients (13%) received the first appropriate therapy after an assumed average ICD battery longevity of 7 years, while in all other patients, the first therapy occurred within the first ICD period. Appropriate interventions were observed more often and earlier in patients with ERP (HR 3.9; 1.4-11.0; P = 0.01), whereas all other covariates failed to predict subsequent events. A high incidence of inappropriate ICD therapies (67 interventions in 14 patients) could be attributed to the occurrence of atrial fibrillation (66% of all inappropriate therapies). CONCLUSION: The recurrence rate of ventricular arrhythmias in iVF survivors is high and recurrence might occur delayed (>7 years after the initial event). ERP seems to be highly predictive with respect to early arrhythmia recurrence. Our results highlight that better pathophysiologic understanding of ERP might facilitate a better risk stratification before and an optimal treatment after an iVF event. The high rate of AF and ERP in iVF survivors might indicate an underlying heart disease or myocardial electrical disorder not apparent at the index event.

When to ablate in Brugada and early repolarization syndromes.

INTRODUCTION: Mapping advances have expanded both the feasibility and benefits of ablation as a therapeutic approach, including in the treatment of two heart conditions that contribute to sudden cardiac death in young people: Brugada syndrome (BrS) and early repolarization syndrome (ERS). Although these conditions share a number of similarities, debates persist regarding the underlying pathophysiology and origin of the ventricular arrhythmias associated with them. AREAS COVERED: By synthesizing available data (PubMed), including current recommendations, pathophysiological insights and case reports, patient registries, our aim is to elucidate and establish the nuanced role of radiofrequency ablation (RFA) in therapeutic management. EXPERT OPINION: RFA is a particularly promising approach in BrS, with a proven long-term benefit. Concerning ERS, RFA seems to be interesting at the price of more complex procedures with more nuanced results.

Electrocardiographic Early Repolarization in an Emergency Setting: The Subtleties of Electrocardiography.

The electrocardiographic pattern of early repolarization (ER) is relatively common in the general population. In patients presenting to the emergency room with chest pain, it can be particularly challenging to distinguish ER from life-threatening subtle ST-segment elevation myocardial infarction (STEMI). A 37-year-old male presented to the emergency department with sudden-onset, severe, non-radiating, central chest pain. The ECG showed Q waves in the inferior leads and a widespread end-QRS notch with J-point elevation mimicking ST elevation in the inferior and lateral precordial leads. Initial cardiac biomarkers were within normal limits. Serial cardiac biomarkers were unremarkable. Echocardiography showed no wall motion abnormalities. A review of prior records from a month ago revealed a similar presentation with similar ECG findings when he underwent cardiac catheterization, revealing normal coronary arteries. Since the ECG was unchanged from the prior one with negative cardiac biomarkers and a negative angiographic study a month ago, no further ischemic risk stratification was indicated. Distinguishing ER from subtle STEMI in patients with acute chest pain can be challenging. A good clinical acumen, along with a comparison of prior ECGs, can aid in decision-making.

Early Repolarization Augmentation Mimicking Pseudo-Infarction in a Patient With Diabetic Ketoacidosis and Normokalemia.

Early repolarization (ER) changes, characterized by J point elevation with or without ST-segment elevation, are dynamic in their presentation and can be exacerbated by factors such as hypothermia, hypercalcemia, vagotonia, and certain medications. There is limited research regarding the mechanism of these changes and the dynamic changes of ER secondary to diabetic ketoacidosis (DKA). This case report highlights the augmentation of early repolarization changes resembling ST-segment elevation myocardial infarction (STEMI) in a patient with DKA that resolved with the treatment of acidosis. The misinterpretation of ER changes on electrocardiogram (ECG) as STEMI or pericarditis may result in the inappropriate utilization of resources, increased patient risk, and elevated morbidity and mortality. Recognition of the potential of DKA to cause ER changes can potentially avoid these unfavorable outcomes.

Relationship between the early repolarization pattern and a history of suicide attempts among drug-free psychiatric patients.

AIM: Suicide attempts are an important severe psychiatric symptom and a clear outcome for mental disorders. Although the relationship between the early repolarization pattern in electrocardiogram and psychiatric disorders has recently been reported, these reports have not been able to exclude the influence of psychiatric drugs. This study aimed to investigate the relationship between the early repolarization pattern and a history of suicide attempts among patients not receiving psychiatric medication. METHODS: A total of 71 patients with a history of suicide attempts were investigated, 38 of whom were analyzed for this study. We compared the frequency of the early repolarization pattern between a suicide attempt group and a control group. Then, we investigated the association between the early repolarization pattern and the suicide attempt group by logistic regression analysis, including electrocardiographic findings associated with psychiatric disorders. RESULTS: The findings indicated that the frequency of the early repolarization pattern was significantly higher in the suicide attempt group (n = 20; 52.6%) than in the control group (n = 4; 10.5%) (P < 0.001), and the results of the logistic regression analysis indicated that the early repolarization pattern was associated with suicide attempts. CONCLUSIONS: These findings suggest that the early repolarization pattern is associated with a history of suicide attempts.

Association of early repolarization pattern and ventricular fibrillation in patients with vasospastic angina: A systematic review and meta-analysis.

BACKGROUND: An early repolarization (ER) pattern is a risk factor for ventricular fibrillation (VF) in patients with vasospastic angina (VSA) caused by a coronary artery spasm. However, its detailed characteristics and prognostic value for VF remain unclear. Thus, we investigated the relationship between ER and VF in patients with VSA. HYPOTHESIS: The ER pattern is associated with VF in patients with VSA. METHODS: In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Library, and Web of Science databases for eligible studies published between January 2011 and December 2020; 8 studies with 1761 patients were included in the final analysis. RESULTS: The ER pattern significantly predicted adverse cardiovascular events (ACEs) and VF (odds ratio [OR] = 5.13, 95% confidence interval [95% CI]: 3.16-8.35, p < .00001 and OR = 5.20, 95% CI: 3.05-8.87, p < .00001). The presence of ER in the inferior leads increased the VF risk (OR = 7.80, 95% CI: 4.04-15.05, p < .00001), regardless of the J-point morphology or type of ST-segment elevation in the ER pattern. A horizontal/descending ST-segment elevation was significantly associated with VF in patients with or without an ER pattern during a coronary spasm (OR = 2.28, 95% CI: 1.07-4.88, p = .03). However, obstructive coronary artery disease was unrelated to the ER pattern (OR = 0.82, 95% CI: 0.27-2.53, p = .73). CONCLUSIONS: An ER pattern is significantly associated with an increased risk of ACE in patients with VSA. An inferior ER pattern with horizontal/descending ST-segment elevation confers the highest risk for VF during VSA onset. Nevertheless, the ER pattern is not associated with obstructive coronary artery disease.