Early repolarization pattern: its ECG characteristics, arrhythmogeneity and heritability.

Early repolarization (ER) has been accepted as a benign ECG variant for decades. Two seminal studies challenged this notion and have demonstrated that ER pattern is associated with an increased risk of arrhythmic and cardiac mortality in patients with idiopathic ventricular fibrillation (IVF) and in the general population. Recent clinical studies demonstrate its varying impact as an arrhythmogenic substrate on different diseases. For example, in ER syndrome, a primary electrical disease, ER appears as a major arrhythmogenic substrate for development of VF whereas in patients with coronary artery disease, an ER pattern may exist as a silent substrate, increasing the risk of VF during episodes of cardiac ischaemia. Due to the high prevalence of an ER pattern in the general population and a low VF event rate, it remains challenging to differentiate a malignant ER pattern from a benign form. Recent research suggests that a J-wave amplitude of more than 0.1 mV combined with a descending/horizontal ST segment may constitute a malignant ER pattern. Further studies are however necessary to evaluate its prognostic value for cardiac and arrhythmic death in the general population as well as in cases with a malignant ER pattern. While genetic testing has revealed putative causal DNA variants in sporadic cases, the lack of co-segregation with the disease in affected families suggests that ER syndrome is not monogenic but is likely a complex disorder influenced by multiple genetic as well as environmental factors.