Early Repolarization

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Electrocardiographic features of early repolarization include diffuse ST elevations that are most pronounced in the precordial leads (typically V2-5) and in proportion to the amplitude of the QRS complex. The degree of ST elevation in V6 should be less than 25% the height of the QRS (greater than 25% suggests pericarditis). J point notching (i.e., “fishhook”) can be seen. The T waves should be concordant (same direction as QRS), and there should not be any reciprocal changes to suggest myocardial infarction. When the diagnosis is in doubt, a calculator to help differentiate early repolarization from a subtle anterior ST-elevation myocardial infarction may be useful.

 

ST elevation can be clearly seen in the above leads. Lead II has J point notching (i.e., “fishhook”), characteristic of early repolarization.

Examples

ECG Showing Early Repolarization

Early Repolarization

There are diffuse, mild, concave ST-segment elevations with J-point notching and absence of reciprocal depressions.
ECG Showing Early Repolarization

Early Repolarization

Notice that the inferior (II, III, and aVF) and lateral leads (V4, V5, V6) have J wave notching (e.g., "fishhook" appearance).
ECG Showing Early Repolarization

Early Repolarization

Early repolarization in a young male. This ECG is classic for early repolarization J notching and diffuse ST-segment elevation.
ECG Showing Early Repolarization

Early Repolarization

This patient received an ECG for reasons unrelated to his presentation and was incidentally noted to have diffuse, concave ST-segment elevation. The degree of ST-segment elevation is greater in the precordial leads, and a prominent J-point notch (or “fishhook”) can be visualized in V3, characteristic of early repolarization.

References

  1. Haïssaguerre M, Derval N, Sacher F, et al. Sudden Cardiac Arrest Associated with Early Repolarization. New England Journal of Medicine. 2008;358(19):2016-2023.
  2. Ginzton LE, Laks MM. The differential diagnosis of acute pericarditis from the normal variant: New electrocardiographic criteria. Circulation. 1982;65(5):1004-1009.
  3. Wagner GS, Strauss DG. Marriott’s Practical Electrocardiography. 12th ed. Lippincott Williams & Wilkins; 2014.
  4. Driver BE, Khalil A, Henry T, Kazmi F, Adil A, Smith SW. A new 4-variable formula to differentiate normal variant ST segment elevation in V2-V4 (early repolarization) from subtle left anterior descending coronary occlusion – Adding QRS amplitude of V2 improves the model. J Electrocardiol. 2017;50(5):561-569.