Author + information
- Celina Yong, MD,
- Victor Froelicher, MD∗ ( and )
- Galen Wagner, MD
- ↵∗Division of Cardiology, Stanford University, Cardiology Division (111C), VA Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, California 94305
Probably no group has done more to make sense of the current confusion regarding early repolarization than our friends from Tel Aviv. Although we agree with their logical conclusions in their recent state-of-the-art paper (1), we would like to add our own concerns regarding terminology and the risk of the electrocardiographic (ECG) patterns they discuss.
We believe that the current nomenclature provides a potentially major cause of confusion (2). “Early repolarization” already has both electrophysiological and ECG definitions. It is the electrophysiological designation of phase 1 of the myocyte action potential, and certainly in the United States, it is also an ECG pattern characterized by normal variant ST-segment elevation. The first reports were from young African-American men (3). Our Israeli colleagues were spared this problem because of the lower prevalence of persons of African descent in their country. It is important to note that most automated ECG programs today make the statement of “early repolarization” based only on ST-segment elevation, without detection of J-wave notches or slurs. We adopted the terms “J-wave pattern/syndrome” in a recent symposium in Journal of Electrocardiology to clarify this distinction (4).
Furthermore, we have concerns whether any pattern of J waves or slurs on a routine electrocardiogram from a stable patient is associated with cardiovascular risk. In 2012, Uberoi et al. (5) reported that the risk of common patterns of early repolarization in an ambulatory population of 30,000 clinic patients with 8-year follow-up was only due to associated Q waves or T-wave inversions. To demonstrate the importance of the ST slope on prognosis, Figure 1 shows the Kaplan-Meier survival curves from the same population. This figure demonstrates the risk of cardiovascular death associated with flat or downsloping ST segments in the inferior and lateral leads, regardless of the presence of J waves.
Although we do not have J waves or slurs coded on the entire sample, we have not found any risk in a subset (6). We recently summarized the available studies dealing with prognosis (7) but have concerns regarding the publication bias for positive studies and the difficulty deciphering their methods for ECG coding (8). In light of these findings, should an ECG pattern that has never been shown to predict cardiovascular risk in any population studies until at least 15 years of follow-up really be considered “malignant”?
Our discussion is not meant to dismiss the large J waves and slurs, particularly the dynamic forms that are an important feature of this new J-wave syndrome (9). However, these occur in rare circumstances.
What is at stake by not resolving these issues? As pointed out by Martini et al. (10), we have already struggled with a syndrome for more than 25 years that has resulted in a “J-ICD reflex,” often in response to a common ECG pattern. We need to examine whether it is truly the J-wave that heralds increased cardiovascular risk or whether this risk is attributable to other ECG abnormalities, with J waves merely the innocent bystander.
Please note: Dr. Wagner has a research contract with AliveCor. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Adler A.,
- Rosso R.,
- Viskin D.,
- et al.
- Uberoi A.,
- Jain N.A.,
- Perez M.,
- et al.
- Yong C.,
- Perez M.,
- Froelicher V.
- Martini B.,
- Wu J.,
- Nava A.