Search

Background: Mortality in patient with acute myocardial infarction has decreased due to evolution in management system in patient with acute coronary syndrome, but mortality rate during hospitalization remains high, especially STEMI. Electrocardiography (ECG) has a role for diagnosing and predict prognosis in acute myocardial infarction. Terminal QRS distortion defined as J point elevation more than 50% of R wave in lead with qR configuration and/or loss of S wave with RS configuration. Changes of terminal QRS segment believed to be caused by electrical conduction elongation in Purkinje fiber or myocardial ischemic zone that represent severe ischemia. The purpose of this study is to assess the role of terminal QRS distortion as one of the parameter to predict major adverse cardiovascular events during hospitalization in ST elevation myocardial infarction in RSUP H. Adam Malik Methods: This is a ambispective observational study consist of STEMI patients who were hospitalized from Mei 2019 to September 2019. All subjects diagnosed with STEMI and already fulfilled the inclusion and exclusion criterias. The terminal QRS distortion on the ECGs was assessed when the patient came to emergency departement. Then during hospitalization, the patients will undergo intervention and then observed during hospitalization for MACE occurrence. Results: Of the 78 STEMI patients, 44 people had terminal QRS distortion and 34 did not have terminal QRS distortion. In group with terminal QRS distortion, 27 people experiences MACE. From the correlation analysis, there is positive correlation between terminal QRS distortion with MACE with correlation coefficient 0.317 (p value < 0.001). Multivariate analysis for most significant variable for MACE occurrence shows that terminal QRS distortion can predict MACE (OR 3.66 [1.317-10.166], 95% CI, p = 0.013) Conclusion: Terminal QRS distortion found in ECG at admission in STEMI patient correlate with major adverse cardiovascular event during hospitalization.

Background: Early repolarization pattern (ERP) is a frequent finding in asymptomatic subjects with controversial implications regarding to its prognosis. This study aims to estimate the prevalence ...

Introduction The significance of high precordial electrocardiograms in idiopathic ventricular fibrillation (IVF) is unknown. Method This study included 50 consecutive patients (48 men; age, 42 ± 18 years) who had spontaneous ventricular fibrillation not linked to structural heart disease and received implantable cardiac defibrillator therapy. IVF was diagnosed in 35 patients and Brugada syndrome was diagnosed in other 15 patients. Electrocardiograms in high intercostal space were compared between 35 patients with IVF and 105 age‐ and sex‐matched healthy controls (patient: control ratio, 1:3). Results The frequency of J point elevation ≥ 0.1 mV in the 4th intercostal spaces was similar between patients with IVF (14%) and healthy controls (7%). However, the frequency of J point elevation ≥ 0.1 mV in the 3rd intercostal space was higher in patients with IVF (40%) than controls (11%) (p

Background and objectives Takotsubo cardiomyopathy (TTC) occasionally causes life-threatening ventricular arrhythmia. J wave on surface electrocardiography (sECG) has also been associated with idiopathic ventricular fibrillation and cardiac events; therefore, we investigated whether the presence of J wave on sECG is a potential risk factor for ventricular arrhythmia in patients with TTC. Subjects and methods We performed a retrospective study in 79 patients who were diagnosed with TTC from 2010 to 2014. Among them, 20 (25.3%) were diagnosed with ventricular tachycardia (VT). The J wave on the sECG was defined as J point elevation manifested through QRS notching or slurring at least 1 mm above the baseline in at least two leads. Results A higher prevalence of ventricular tachycardia was observed in patients with J wave. The corrected QT interval (QTc) was significantly longer in the VT group than in the non-VT group. In a multivariate analysis, the presence of J wave appeared to be the only independent predictors of VT [Hazard Ratio (HR) 3.5, p = 0.019]. Conclusion Our results suggest that the presence of J wave on the sECG is significantly associated with VT, and appear to indicate that the presence of J wave is a strong and independent predictor of VT in patients with TTC.

A J wave is a common electrocardiographic finding in the general population. Individuals with prominent J waves in multiple electrocardiogram (ECG) leads have a higher risk of lethal arrhythmias than those with low-amplitude J waves. There are few reports about the relationship between thyroid function and J-wave amplitude. We report the case of a 45-year-old man who had unexpected ventricular fibrillation (VF). He had dynamic J-point elevation in multiple ECG leads. Possible early repolarization syndrome was diagnosed. He also had thyrotoxicosis caused by silent thyroiditis, and his J-wave amplitude decreased according to changes in thyroid function because of spontaneous remission of silent thyroiditis. There was a positive correlation between serum triiodothyronine levels and J-wave amplitudes. The findings in case suggested silent thyroiditis may contribute to the occurrence of VF in a patient with dynamic changes in J-point elevation in multiple ECG leads. Thyrotoxicosis is a relatively common endocrine disease; therefore, clinicians should pay attention to J-wave amplitude in the ECG of patients with thyrotoxicosis., This case suggests silent thyroiditis may contribute to the occurrence of VF associated with J-point elevation. There was a correlation between serum triiodothyronine levels and J-wave amplitudes.

Background Prevalence of early repolarisation ECG pattern (ER) has been repetitively determined in adults, but has not been reported in large unselected children populations so far. Methods ECG from 1000 successive healthy children from birth to 17years old were prospectively recorded and analyzed. ER was defined by ≥0.1mV J point elevation in at least two contiguous inferior or lateral ECG leads. Correlations with age, gender, ethnic origin, physical activity, Sokolow index and heart rate were performed. Results Prevalence of ER pattern was 23,6% (95% CI 21–26.2%) and increased after 8years of age. ER was independently correlated to a non Caucasian origin and a higher Sokolow index, but not to gender or level of physical activity. ER was independently correlated to an older age in children with heart rate Conclusion ER is present in a quarter of children of various age and is related to ethnic origin, an older age, a slower heart rate and a higher Sokolow index.

Risk Stratification in Type 1 Brugada PatternIntroduction Risk stratification of asymptomatic patients with a Brugada type 1 ECG pattern remains an unresolved clinical conundrum. In contrast to provocative pharmacological testing in Brugada syndrome, there is limited data on the role of exercise stress testing as a risk stratification modality. The objective of this study was to evaluate the utility of exercise testing in asymptomatic patients with type 1 Brugada pattern to prognosticate major arrhythmic events (MAE) during follow-up. Methods and Results Treadmill exercise testing was conducted for 75 asymptomatic patients with type 1 Brugada pattern and for 88 healthy control subjects. The clinical end point of MAE was defined as the occurrence of sudden cardiac death (SCD) or resuscitated ventricular fibrillation (VF). During a follow-up of 77.9 ± 28.9 months, eight MAE occurred (five VF and three SCD). Multivariate Cox regression analysis showed that the following were independent predictors of MAE in asymptomatic patients with a type 1 Brugada pattern: increase in S wave upslope duration ratio >30% at peak exercise (HR 1.35, 95% CI 1.08–10.97, P = 0.023), augmentation of J point elevation in lead aVR >2 mm in late recovery (HR 1.88, 95% 1.21–15.67, P = 0.011), and delayed HR recovery (HR 1.14, 95% CI 1.06–18.22, P = 0.042). A high-risk cohort was identified by the final step-wise regression model with good accuracy (specificity = 98.4%, sensitivity = 62.5%) and discriminative power (AUC = 0.93, 95% CI 0.89–0.96, P = 0.002). Kaplan–Meier analysis revealed increasing MAE in subjects with one, two, or three predictors, respectively (log rank P < 0.001). Conclusions Exercise testing in asymptomatic patients with type 1 Brugada pattern aids in identification of high-risk patients and provides a unique window of opportunity for early intervention.

In 1992, R. Brugada and J. Brugada were the first to describe a syndrome characterized by right-bundle branch block (RBBB) with ST segment elevation followed by an inverted T-wave in the right precordial leads, which predisposes apparently healthy subjects to Sudden Cardiac Death (SCD).

Background Just as high-risk populations for cardiac arrest exist in patients with Brugada syndrome or long QT syndrome, high-risk and low-risk populations for cardiac arrest also exist in patients with early repolarization pattern (ERP). Hypothesis Electrocardiographic (ECG) characteristics can aid the risk stratification of patients with ERP. Methods Electrocardiographic parameters such as magnitude of J-point elevation and J/R ratio were measured. The magnitude of J-point elevation, leads with J points elevated, J/R ratio, morphology of the ST segment, and QT/QTc interval were used in comparative analysis in 2 groups: 57 patients with ERP and cardiac arrest (cardiac arrest group) and 100 patients with ERP but without cardiac arrest (control group). Results There was no statistical difference in clinical characteristics of the 2 groups. The J/R ratio in the cardiac arrest group was significantly higher than in the control group (26.8% ± 18.1% vs 16.3% ± 10.3%, respectively; P < 0.001) and the proportion of horizontal/descending ST segments (70.2%) was significantly higher than in the control group (29.0%), but the proportion of ascending/upsloping ST segments (29.8%) was significantly lower than in the control group (71.0%; P < 0.001). Multivariate logistic regression revealed that higher J/R ratio and horizontal/descending ST segment were independently associated with increased risk of cardiac arrest in patients with ERP. Conclusions In patients with ERP and cardiac arrest, J/R ratios were relatively higher and mostly with horizontal/descending ST segments, suggesting that J/R ratio and ST-segment morphology may be used as indicators for risk stratification in patients with ERP.

We report the case of a 19-year-old male who successfully recovered from sudden cardiac arrest. Careful evaluation did not reveal any electrical or structural abnormalities. He underwent implantable cardioverter defibrillator (ICD) implantation, with a diagnosis of idiopathic ventricular fibrillation (VF). Three months later, VF recurred and was successfully terminated by ICD shock. Electrocardiogram (ECG) revealed a slurred type J point elevation at the inferolateral leads with a horizontal/descending ST segment change, which was not present during the initial hospitalization. Cilostazol was prescribed to prevent further lethal ventricular arrhythmias. Subsequently, no arrhythmic events were reported, and the J wave disappeared at the follow-up ECG. However, recurrent VF episodes with an interval of 1–2 weeks occurred 1 year later, and were terminated by ICD shock. Simultaneous ECG revealed a J point elevation at the inferolateral leads. Cilostazol was replaced by quinidine. Subsequently, no arrhythmic event recurred for over 12 months. Serial follow-up ECG is needed to identify masked inherited primary arrhythmic syndromes in sudden cardiac arrest survivors diagnosed with idiopathic VF. Cilostazol and quinidine might be good therapeutic options to prevent further lethal events in cases where the J wave syndrome is present with recurrent ventricular arrhythmias.

Early repolarization (ER) pattern is a prominent J point (end-QRS notch or slur) with an elevation ≥0.1 mV in two or more contiguous leads (excluding V1-V3) in a 12-lead electrocardiogram (ECG). Furthermore, the QRS duration is required to be

Conflicting data exist regarding the associations of early repolarization (ER) with electrocardiogram (ECG) and clinical outcomes in blacks. We examined the association of ER defined by J point elevation (JPE) and all-cause mortality, and heart failure (HF) hospitalization in blacks in the Jackson Heart Study (JHS) cohort. We included JHS participants with ECGs from the baseline visit coding JPE and excluded participants with paced rhythms or QRS duration ≥120 ms. We compared the cumulative incidence of 10-year all-cause mortality and 8-year HF hospitalization by presence of JPE ≥0.1 mV in any ECG lead at baseline using Kaplan-Meier estimates and multivariable Cox models. Of the 4,978 participants, 1,410 (28%) had JPE at baseline: anterior leads 97.8%, lateral leads 8.3%, and inferior leads 2.9%. Compared with participants without JPE, those with JPE were younger, more likely to be male and current smokers, and less likely to have hypertension. Over a median follow-up of 8 years, there were no significant differences in the cumulative incidence or multivariable-adjusted hazards of all-cause mortality or HF hospitalization in participants with and without JPE in any lead (adjusted hazard ratio 0.97, 95% confidence interval 0.89 to 1.52, and adjusted hazard ratio 1.18, 95% confidence interval 0.9 to 1.54, respectively). Of the 2,523 participants who completed Exam 3 without JPE at baseline, 246 (10%) developed JPE over follow-up. In conclusion, JPE on ECG was not associated with long-term mortality or HF hospitalization in a large prospective black community cohort, suggesting that ER may represent a benign ECG finding in blacks.

Aims Anterior T-wave inversion (TWI) is a recognized variant in athletes of African/Afro Caribbean origin and some endurance athletes; however, the presence of this specific repolarization anomaly also raises the possibility of cardiomyopathy. The differentiation between physiological adaptation and cardiomyopathy may be facilitated by examining other repolarization parameters, notably the J-point and the ST-segment. Methods and results We compared the electrocardiogram pattern of anterior TWI in a series of 80 healthy athletes (median age 21 years, 75% males); 95 patients with hypertrophic cardiomyopathy (HCM) (median age 46 years, 75% males), including 26 affected athletes; and 58 patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) (median age 32 years, 71% males), including 9 affected athletes. Athletes and patients were of either white/Caucasian or black/Afro Caribbean descent and showed TWI ≥1 mm in ≥2 contiguous anterior leads (V1–V4). We aimed to identify repolarization patterns for differentiating physiologic from pathologic TWI. After adjustment for age, gender, and ethnicity, J-point elevation

Background J wave, or early repolarization has recently been associated with an increased risk of lethal arrhythmia and sudden death, both in idiopathic ventricular fibrillation and in the general population. Hypercalcemia is one of the causes of J point and ST segment elevation, but the relationship has not been well studied. The aim of this study was to examine the effects of hypercalcemia on J point elevation. Methods Electrocardiographic findings were compared in 89 patients with hypercalcemia and 267 age- and sex-matched healthy controls with normocalcemia. The association of J point elevation with arrhythmia events in patients with hypercalcemia was also studied. Results The PR interval and the QRS duration were longer in patients with hypercalcemia than in normocalcemic controls. Both the QT and the corrected QT intervals were shorter in patients with hypercalcemia compared with normocalcemic controls. Conduction disorders, ST-T abnormalities, and J point elevation were more common in patients with hypercalcemia than normocalcemic controls. Following the resolution of hypercalcemia, the frequency of J point elevation decreased to a level similar to that noted in controls. During hospitalization, no arrhythmia event occurred in patients with hypercalcemia. Conclusion Hypercalcemia was associated with J point elevation.

Conflicting data exist regarding the associations of early repolarization (ER) with electrocardiogram (ECG) and clinical outcomes in blacks. We examined the association of ER defined by J point elevation (JPE) and all-cause mortality, and heart failure (HF) hospitalization in blacks in the Jackson Heart Study (JHS) cohort. We included JHS participants with ECGs from the baseline visit coding JPE and excluded participants with paced rhythms or QRS duration ≥120 ms. We compared the cumulative incidence of 10-year all-cause mortality and 8-year HF hospitalization by presence of JPE ≥0.1 mV in any ECG lead at baseline using Kaplan-Meier estimates and multivariable Cox models. Of the 4,978 participants, 1,410 (28%) had JPE at baseline: anterior leads 97.8%, lateral leads 8.3%, and inferior leads 2.9%. Compared with participants without JPE, those with JPE were younger, more likely to be male and current smokers, and less likely to have hypertension. Over a median follow-up of 8 years, there were no significant differences in the cumulative incidence or multivariable-adjusted hazards of all-cause mortality or HF hospitalization in participants with and without JPE in any lead (adjusted hazard ratio 0.97, 95% confidence interval 0.89 to 1.52, and adjusted hazard ratio 1.18, 95% confidence interval 0.9 to 1.54, respectively). Of the 2,523 participants who completed Exam 3 without JPE at baseline, 246 (10%) developed JPE over follow-up. In conclusion, JPE on ECG was not associated with long-term mortality or HF hospitalization in a large prospective black community cohort, suggesting that ER may represent a benign ECG finding in blacks.

The early repolarization pattern and J wave were recognized during the very early period after the invention of the ECG. While the J wave has been reported to become prominent in particular circumstances, i.e., hypothermia, hypercalcemia, and brain damages, early repolarization has long been considered to be a benign finding, which is attributable to the definition of early repolarization during the period that included not only end-QRS notching/slurring but also ST segment elevation continuing to the upward concave ST segment and tall T wave. The prevalence of an early repolarization pattern and its predictive value has varied widely among the studies published more recently, which presumably were due to the diversity of the definitions. In the reports, either in case control studies or population studies, showing an association between an early repolarization pattern and cardiac or arrhythmic death, the definition has been based on J point elevation with notched or slurred J wave in the inferior or lateral leads, while early repolarization based on ST segment elevation seldom has shown any increased risk. The accumulated evidence has also demonstrated that even in those with J point elevation, the arrhythmic risk does not increase with a concave ST segment morphology. The definition of an early repolarization pattern should be unified and standardized to better stratify the risk of arrhythmic death.

Whatever the terminology which will be further used, either early repolarization (ER), Haissaguerre or J wave syndrome, it should never be forgotten that the ECG pattern associating various degrees of J point elevation, slurring or notching of the terminal part of the QRS and further ST elevation has been described well before the recent growing interest of electrophysiologists for this entity and was and should be still considered – as a normal ECG variant, at least in the very largest part of the normal population. Although this introductive assumption is far from original, it is worth to be recalled, because we should never lose sight of a feature that is present in several percent of the normal population cannot be considered as abnormal. Historically, one can track the first description of this pattern as soon as 1936, followed by some other reports over the last half of the previous century. At this step, the pattern was essentially described as ST elevation with a distinct notch or slur on the downslope of the R wave and was described as a “normal variant”, “unusual RT segment deviation”, “normal RST elevation variant” related to a “persistent juvenile pattern”, reflecting the belief of lack of any harmful consequence carried by this ECG pattern at this time. The clinical relevance of the documentation of this ECG pattern in a given patient however is not negligible, since it may mimick pericarditis, acute myocardial infarction or hypothermia for example, and may be associated, although in a very limited subset of patients, to sudden death (see other chapters from this issue). If we now carefully look at the publications relying on the prevalence of “early repolarization" pattern in the normal population, we can see that very various rates have been observed (roughly 1–15% according to most of the studies compiled in Table 2). These rather large differences are believed to reflect some differences in the definition (ST elevation or J wave) or methods to diagnose the pattern (manual vs automatic analysis for example), as well as differences in the studied population. Moreover, for some authors the QRS possibly includes the J wave/slurring – so

In the past years a renewed interest has emerged in the implications of aberrant terminal R waves or J-ST segments, J point elevation and J waves on the electrocardiogram of patients without evidence of gross structural cardiac abnormalities because of the association with malignant arrhythmias and (familial) sudden death. There have been propositions to group selected clinical entities (Brugada syndrome and early repolarization syndrome) of which the principal electrocardiographic element consists of these electrographic phenomena under the broader term J wave syndromes. In this paper such a grouping is discussed

Brugada syndrome is an inherited cardiac arrhythmia condition characterized by coved-type ST elevation and J point elevation of at least 2 mm in at least 2 of the right precordial electrocardiogram (ECG) leads (V1–3). An increasing number of noncardiac agents, including psychotropic and anesthetic drugs, have been shown to induce a characteristic Brugada ECG pattern, predisposing the patient to fatal ventricular arrhythmias. However, there are scarce data regarding the clinical significance. In this case series, a typical Brugada pattern was unmasked by lithium, valproic acid, and thiocolchicoside; however, the clinical scenario was different in all 3 cases, ranging from an asymptomatic patient to sudden cardiac arrest.

Hypocalcemia is mainly the consequence of hypoalbuminemia, advanced renal impairment, cirrhosis, malnutrition, or sepsis. The most common ECG manifestation of hypocalcemia is QT prolongation as a result of ST segment lengthening. Very occasionally, hypocalcemia can manifest with ST segment elevation forcing the differential diagnosis with ST elevation MI. We described a case of severe hypocalcemia manifesting in electrocardiogram with a J point elevation, absent of ST segment and with associated short QT interval mimicking acute myocardial infarction.

The early repolarization (ER) pattern on the 12-lead electrocardiogram is characterized by J point elevation in the inferior and/or lateral leads. The ER pattern is associated with an increased risk of ventricular arrhythmias and sudden cardiac death (SCD). Based on studies in animal models and genetic studies, it has been proposed that J point elevation in ER is a manifestation of augmented dispersion of repolarization which creates a substrate for ventricular arrhythmia. A competing theory regarding early repolarization syndrome (ERS) proposes that the syndrome arises as a consequence of abnormal depolarization. In recent years, multiple clinical studies have described the characteristics of ER patients with VF in more detail. The majority of these studies have provided evidence to support basic science observations. However, not all clinical observations correlate with basic science findings. This review will provide an overview of basic science and genetic research in ER and correlate basic science evidence with the clinical phenotype.

The J wave, a deflection that follows the QRS complex of the surface electrocardiogram, is usually partially buried in the R wave in humans, appearing as a J-point elevation. An early repolarization (ER) pattern characterized by J-point elevation, slurring of the terminal part of the QRS, and ST-segment elevation has long been recognized and considered to be totally benign. Recent studies have presented evidence demonstrating that an ER pattern in inferior leads or inferolateral leads is associated with increased risk for life-threatening arrhythmias, named early repolarization syndrome. Early repolarization syndrome and Brugada syndrome share similar electrocardiographic characteristics, clinical outcomes, risk factors, as well as a common arrhythmic platform related to amplification of I(to)-mediated J waves. Although Brugada syndrome and early repolarization syndrome differ with respect to the magnitude and lead location of abnormal J wave manifestation, they can be considered to represent a continuous spectrum of phenotypic expression, termed J-wave syndromes. Early repolarization syndrome has been proposed to be divided into 3 subtypes: type 1, displaying an ER pattern predominantly in the lateral precordial leads, is prevalent among healthy male athletes and rarely seen in ventricular fibrillation survivors; type 2, displaying an ER pattern predominantly in the inferior or inferolateral leads, is associated with a higher level of risk; whereas type 3, displaying an ER pattern globally in the inferior, lateral, and right precordial leads, is associated with the highest level of risk for development of malignant arrhythmias and is often associated with ventricular fibrillation storms.

Objectives The purpose of this study was to assess the prevalence of J-point elevation among the relatives of sudden arrhythmic death syndrome (SADS) probands. Background J-point elevation is now known to be associated with idiopathic ventricular fibrillation. We hypothesized that this early repolarization phenomenon is an inherited trait responsible for a proportion of otherwise unexplained SADS cases. Methods Families of SADS probands were evaluated in an inherited arrhythmia clinic. Twelve-lead electrocardiograms were analyzed for J-point elevation defined as >0.1 mV from baseline present in 2 or more of the inferior (II, III, and aVF) or lateral (1, aVL, V4 to V6) leads. Electrocardiographic data were compared with those of 359 controls of a similar age, sex, and ethnic distribution. Results A total of 363 first-degree relatives from 144 families were evaluated. J-point elevation in the inferolateral leads was present in 23% of relatives and 11% of control subjects (odds ratio: 2.54, 95% confidence interval: 1.66 to 3.90; p Conclusions J-point elevation is more prevalent in the relatives of SADS probands than in controls. This indicates that early repolarization is an important potentially inheritable pro-arrhythmic trait or marker of pro-arrhythmia in SADS.

The electrocardiographic J wave, also referred as the Osborn wave, is a deflection with a dome or hump morphology at the junction between the QRS complex and the ST segment on the body surface ECG. Earlier studies attributed the J wave to a variety of factors including hypoxia, injury current, acidosis, delayed ventricular depolarization, and early ventricular repolarization.1 Clinical and arrhythmogenic significance of the J wave abnormalities had largely been ignored until 1996 when Yan and Antzelevitch published a study elucidating the ionic and cellular basis of the J wave, indicating that a prominent Ito-mediated action potential notch in ventricular epicardium but not endocardium may produce a transmural voltage gradient during early ventricular repolarization that could register as a J wave or J point elevation in the ECG.2 Growing evidence has since been advanced indicating that J wave abnormalities, which are often accompanied by early repolarization and ST segment elevation on the ECG, are in some cases associated with a risk of sudden cardiac death. The J wave syndromes, which represent a variable spectrum of phenotypic expression with accentuation of the J wave, can be inherited or acquired.3–6 This review attempts to summarize current knowledge about J-wave syndromes- linking bench work with the bedside.

The J wave, also referred to as an Osborn wave, is a deflection immediately following the QRS complex of the surface ECG. When partially buried in the R wave, the J wave appears as J-point elevation or ST-segment elevation. Several lines of evidence have suggested that arrhythmias associated with an early repolarization pattern in the inferior or mid to lateral precordial leads, Brugada syndrome, or arrhythmias associated with hypothermia and the acute phase of ST-segment elevation myocardial infarction are mechanistically linked to abnormalities in the manifestation of the transient outward current (I(to))-mediated J wave. Although Brugada syndrome and early repolarization syndrome differ with respect to the magnitude and lead location of abnormal J-wave manifestation, they can be considered to represent a continuous spectrum of phenotypic expression that we propose be termed J-wave syndromes. This review summarizes our current state of knowledge concerning J-wave syndromes, bridging basic and clinical aspects. We propose to divide early repolarization syndrome into three subtypes: type 1, which displays an early repolarization pattern predominantly in the lateral precordial leads, is prevalent among healthy male athletes and is rarely seen in ventricular fibrillation survivors; type 2, which displays an early repolarization pattern predominantly in the inferior or inferolateral leads, is associated with a higher level of risk; and type 3, which displays an early repolarization pattern globally in the inferior, lateral, and right precordial leads, is associated with the highest level of risk for development of malignant arrhythmias and is often associated with ventricular fibrillation storms.

Background Early repolarization, which is characterized by an elevation of the QRS–ST junction (J point) in leads other than V1 through V3 on 12-lead electrocardiography, has been associated with vulnerability to ventricular fibrillation, but little is known about the prognostic significance of this pattern in the general population. Methods We assessed the prevalence and prognostic significance of early repolarization on 12-lead electrocardiography in a community-based general population of 10,864 middle-aged subjects (mean [±SD] age, 44±8 years). The primary end point was death from cardiac causes, and secondary end points were death from any cause and death from arrhythmia during a mean follow-up of 30±11 years. Early repolarization was stratified according to the degree of J-point elevation (≥0.1 mV or >0.2 mV) in either inferior or lateral leads. Results The early-repolarization pattern of 0.1 mV or more was present in 630 subjects (5.8%): 384 (3.5%) in inferior leads and 262 (2.4%) in lateral leads,...

Objectives The purpose of this study was to determine whether J-point elevation is a marker of arrhythmic risk. Background J-point elevation has been considered an innocent finding among healthy young individuals (the “early repolarization” pattern). However, this electrocardiogram (ECG) finding is increasingly being associated with idiopathic ventricular fibrillation (VF). Methods In a case-control study, the ECG of 45 patients with idiopathic VF were compared with those of 124 age- and gender-matched control subjects and with those of 121 young athletes. We measured the height of J-point and ST-segment elevation and counted the presence of slurring in the terminal portion of the R-wave. Results J-point elevation was more common among patients with idiopathic VF than among matched control subjects (42% vs. 13%, p 0.001). This was true for J-point elevation in the inferior leads (27% vs. 8%, p 0.006) and for J-point elevation in leads I to aVL (13% vs. 1%, p 0.009). J-point elevation in V4 to V6 occurred with equal frequency among patients and matched control subjects (6.7% vs. 7.3%, p 0.86). Male subjects had J-point elevation more often than female subjects and young athletes had J-point elevation more often than healthy adults but less often than patients with idiopathic VF. The presence of ST-segment elevation or QRS slurring did not add diagnostic value to the presence of J-point elevation. Conclusions J-point elevation is found more frequently among patients with idiopathic VF than among healthy control subjects. The frequency of J-point elevation among young athletes is intermediate (higher than among healthy adults but lower than among patients with idiopathic VF). (J Am Coll Cardiol 2008;52:1231‐8) © 2008 by the American College of Cardiology Foundation

Introduction: Myocardial cooling can induce J point elevation (Osborn wave) as seen on ECG of the Brugada syndrome by activating transient outward current (Ito) and causing a spike-and-dome configuration of the monophasic action potential (MAP) in the ventricular epicardium in isolated canine ventricular wedge preparations. We determined the effect of regional epicardial cooling of the right ventricular outflow tract (RVOT) on surface ECG and ventricular vulnerability in the dog. Methods and Results: In 12 dogs, a cooling device (20-mm diameter) was attached to the RVOT epicardium, and surface ECG, epicardial MAP, and endocardial MAP were recorded. Regional cooling (29.7°C ± 2.2°C) elevated the J point from 0.05 ± 0.06 mV to 0.12 ± 0.11 mV and induced T wave inversion (from 0.02 ± 0.12 mV to −0.27 ± 0.20 mV) in lead V1 in association with “spike-and-dome” configuration of the epicardial MAP. Cooling prolonged MAP duration in the RVOT epicardium from 172 ± 27 ms to 213 ± 30 ms (P < 0.01) but not in the RV endocardium and increased transmural dispersion of MAP duration from 9 ± 8 ms to 44 ± 21 ms (P < 0.01). Cooling also prolonged the QT interval in lead V1 from 191 ± 19 ms to 212 ± 23 ms (P < 0.05), but not in lead V5, and increased spatial dispersion of QT interval from 7 ± 5 ms to 20 ± 10 ms (P < 0.01). QT interval in lead V1 correlated positively with MAP duration in the RVOT epicardium (r = 0.75). T wave amplitude in lead V1 correlated inversely with transmural dispersion of MAP duration in the RVOT (r =−0.74). Vagal nerve stimulation accentuated the cooling-induced changes. During cooling, ventricular fibrillation was induced by a single extrastimulus in 2 of 4 dogs, and additional vagal nerve stimulation during isoproterenol administration induced spontaneous ventricular fibrillation in one dog. Conclusion: Localized epicardial cooling of the RVOT could be an in vivo experimental model of Brugada syndrome. (J Cardiovasc Electrophysiol, Vol. 15, pp. 936-941, August 2004)

The early repolarization (ER) pattern is a particular EKG aspect first described in 1936 by Shipley and Hallaran as a normal variant of repolarization. Subsequently Haissaguerre et al proposed a new ER classification characterized by J point elevation associated with J wave and ST-segment elevation or a horizontal/descending ST segment. A recent meta-analysis shows that the ER pattern was associated with high risk of all-cause mortality if characterized by a notched J wave with a horizontal/descending ST elevation and T waves discordant to their respective ST-segment deviation (

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Brugada syndrome is an autosomal dominant disorder caused by loss of function mutation(s) involving the SCN5A sodium channel that is associated with sudden cardiac death. It has a characteristic pattern on ECG consisting of ST segment elevations in V1 to V3 and J point elevation of at least 2mm.

See article by Taggart et al. [50] (pages 454-462) in this issue. Studies conducted over the past dozen years or so have demonstrated that ventricular myocardium is not homogeneous, as previously thought, but is comprised of at least three electrophysiologically distinct cell types: epicardial, M and endocardial cells (see [1,2] for reviews). These three cell types have also been shown to possess different pharmacologic profiles and to respond differently to a variety of pathophysiologic states [3–8]. The three cells types differ principally with respect to repolarization characteristics. Ventricular epicardial and M cells display action potentials with a prominent transient outward current ( I to)-mediated phase 1, giving rise to a notched appearance of the action potential. The absence of a prominent notch in the endocardium is a consequence of a much smaller I to. Similar regional differences in I to are found in canine, feline, rabbit, rat and human ventricular myocytes (see [1] for references). Recent studies also indicate that I to and the action potential notch are much larger in right vs. left ventricular epicardial [9] and M [10] cells. The transmural gradient in the amplitude of the I to-mediated action potential notch underlies the normal J wave or J point elevation in the ECG [11] and its accentuation, particularly in the right ventricle, contributes to the development of life-threatening arrhythmias in patients with the Brugada syndrome and various forms of idiopathic ventricular fibrillation [12,13]. The presence of a prominent I to in right ventricular epicardium has also been shown to sensitize this tissue to the effects of ischemia [14]. Accentuation of the action potential notch and eventual loss of the dome in right ventricular epicardium but not endocardium has been shown to contribute to ischemia-induced ST segment elevation [12]. The M cells are … *Tel.: +1-315-735-2217; fax: +1-315-735-5648 ca{at}mmrl.edu

Recurrent ventricular fibrillation was observed in a 29-year-old Vietnamese man who did not exhibit structural heart disease. The patient's ECG showed prominent J (Osborn) waves and ST segment elevation in the inferior leads that were not associated with hypothermia, serum electrolyte disturbance, or myocardial ischemia. Rate-dependent change in the amplitude of J waves and ST segment elevation also were observed. An implantable cardioverter defibrillator (ICD) was implanted. Adjunctive treatment with amiodarone reduced J wave amplitude, preventing ventricular fibrillation and ICD shocks. Prominent J waves and ST segment elevation in the inferior leads may serve as an important diagnostic sign to detect high-risk individuals with a history of unexplained syncope. ICD implantation plus amiodarone is the treatment of choice.

Background— J-point elevation is common in athletes; nevertheless, the influence of structural changes associated with the athlete’s heart and its prognostic impact are still debated. Our aim was to investigate the prevalence of J-point elevation, the associated clinical, electrocardiographic, and echocardiographic characteristics and its impact on long-term outcome in elite soccer players. Methods and Results— Clinical, electrocardiographic, and cardiopulmonary exercise test data from 332 male professional soccer players were retrospectively analyzed. For 235 (70.7%) athletes echocardiographic data were also available. J-point elevation was defined as an elevation ≥1 mm in ≥2 contiguous leads. Long-term follow-up data were obtained for all athletes, whereas univariate and multivariable analyses were performed to assess the associated characteristics. Overall, 118 (35.6%) athletes showed a J-point elevation ≥1 mm. At multivariable analysis a significant direct association of interventricular septum thickness (odds ratio for 1 SD increase, 1.361; 95% confidence interval, 1.019–1.817; P =0.036) and Sokolow–Lyon index (odds ratio for 1 SD increase, 1.367; 95% confidence interval, 1.026–1.822; P =0.033) and an inverse association of baseline heart rate (odds ratio for 1 SD increase, 0.686; 95% confidence interval, 0.508–0.927; P =0.011) with J-point elevation were observed. During a long-term follow-up (median, 13.3 years; first and third quartiles, 10.1–17.0 years), a low mortality rate was observed, not related to cardiovascular causes. Conclusions— The correlation between J-point elevation and interventricular septum thickness suggests a possible mechanistic role of exercise-induced left ventricular hypertrophy as the basis for J-point elevation. After a long-term follow-up, no cardiac death was observed.

We investigated whether the presence of J wave on the surface electrocardiography (sECG) could be a potential risk factor for ventricular fibrillation (VF) during acute myocardial infarction (AMI). We performed a retrospective study of 317 patients diagnosed with AMI in a single center from 2009 to 2012. Among the enrolled 296 patients, 22 (13.5%) patients were selected as a VF group. The J wave on the sECG was defined as a J point elevation manifested through QRS notching or slurring at least 1 mm above the baseline in at least two leads. We found that the incidence of J wave on the sECG was significantly higher in the VF group. We also confirmed that several conventional risk factors of VF were significantly related to VF during AMI; time delays from the onset of chest pain, blood concentrations of creatine phosphokinase and incidence of ST-segment elevation. Multiple logistic regression analysis demonstrated that the presence of J wave and the presence of a ST-segment elevation were independent predictors of VF during AMI. This study demonstrated that the presence of J wave on the sECG is significantly related to VF during AMI. Graphical Abstract Keywords: J Wave, Ventricular Fibrillation, Acute Myocardial Infarction INTRODUCTION Primary ventricular fibrillation (PVF) during acute myocardial infarction (AMI) refers to VF that occurs early (usually < 48 hr post myocardial infarction), and is not associated with recurrent ischemia or heart failure (1). The incidence of VF was reported to be more than 10% during AMI, and VF usually occurs in a few hours after the onset of chest pain (1). VF is the most frequent cause of death in association with AMI because it usually occurs before medical contact (1). Recent studies have demonstrated that J wave on the sECG has been associated with idiopathic VF in patients who do not have structural heart disease (2). A recent study also reported that the presence of J wave is associated with ventricular arrhythmia in patients who have chronic coronary artery disease (3). So far, few studies reported that the presence of J wave in sECG is associated with VF during AMI (1, 4, 5, 6). Several variables, including J wave, were reported as significant predictors of VF, but failed to get statistical significance. Through this study, we planned to evaluate that the presence of J wave on the sECG could be a potential risk factor for VF during AMI.

Aims A retrospective, case–control study to investigate the J wave, a J-point elevation on resting 12-lead electrocardiograms, as a risk factor for sudden cardiac arrest (SCA) in patients diagnosed with hypertrophic cardiomyopathy (HCM). Methods Patients with HCM and age- and sex-matched healthy control subjects were recruited, and 12-lead electrocardiograms were performed. The prevalence and related characteristics of J waves were assessed. Patients were followed-up for a mean of 47.9 months. Results Patients with HCM ( n = 345) had significantly higher prevalence of J waves than healthy controls ( n = 690; 11.6% and 7.1%, respectively). During follow-up, 14 patients with HCM experienced SCA (SCA subgroup). The prevalence of J waves was significantly higher in the SCA subgroup than in the non-SCA subgroup (42.9% and 10.3%, respectively). There were no significant differences between the SCA and non-SCA subgroups in J wave morphology. Conclusion The J wave may be a risk factor for SCA in patients with HCM.

extensive efforts including genetic screening, sophisticated imaging modalities, and the participation of hundreds of thousands of patients in clinical trials, CAD and its sequelae still represent the vast majority of the underlying cause of SCD. Yet even amongst the millions who live with CAD and experience myocardial infarctions each year, only a fraction experience life threatening ventricular arrhythmias. The ability to identify the patients at highest risk of SCD could lead to improved prevention measures in this population and save thousands of lives. Therefore, novel tools to stratify risk of SCD in patients with CAD are sorely needed. Recent work has identified the J wave pattern, as a risk factor for SCD in the general population as well as in patients with CAD 2–7 – quite a profound change for a pattern previously thought to be benign. Though the presence of the J wave pattern does not explain all the risk of SCD in either population, this review will examine the role of the J wave pattern as a novel risk factor for SCD specifically in a high risk population, patients with CAD. Of note, this pattern defined as an elevation of the QRS–ST junction of at least 0.1 mV from baseline and QRS slurring or notching in at least two contiguous leads in the inferior or lateral location on ECG has previously been described as early repolarization. 2 However, as the definition focuses on J point elevation associated with notches or slurs rather than the ST segment elevation classically associated with early repolarization, for the purposes of this review, we use the term J wave pattern to describe the ECG pattern labeled as early repolarization in many of the studies reviewed.

Early repolarization (ER) was initially defined as STsegment elevation not associated with coronary artery disease (CAD) or pericarditis occurring in healthy individuals. The finding was considered benign and commonly seen in younger age groups, athletes, African Americans and bradycardic individuals. Later, the ST elevation was noted to often occur with J waves and slurs. Focusing on the slurs and J waves and ignoring the ST elevation, Haissaguerre et al. found that a cohort of patients with idiopathic VF exhibited a higher proportion of J wave pattern compared to controls. Since then multiple population and cohort studies evaluated the clinical and prognostic implications of J wave pattern and ER and have yielded mixed results. Studies attempted to refine their results by identifying subgroups that are at higher risk such as ST segment slope and concomitant ECG signs of structural heart disease. This review aims to provide an overview of studies examining the relationship of concomitant electrocardiogram (ECG) findings that interact with the J wave pattern to modulate risk and shed some light on the interaction observed in these studies. The term ER is used to refer to electrocardiographic phenomenon of ST elevation and J wave pattern is used to refer to J point elevation associated with notches or slurs. Studies of both ECG patterns are examined in an attempt to discern a relationship between these theoretically related phenomena. However it is recognized that the risk dictated by each ECG finding is probably not equivalent adding to the confusion in interpreting the data. Adopting more consistent definitions of the ECG phenomenon described may help identify the precise risk associated with the finding.

An early repolarization (ER) pattern in the ECG, consisting of J point elevation, distinct J wave with or without ST segment elevation or slurring of the terminal part of the QRS, was long considered a benign electrocardiographic manifestation. Experimental studies a dozen years ago suggested that an ER is not always benign, but may be associated with malignant arrhythmias. Validation of this hypothesis derives from recent case-control and population-based studies showing that an ER pattern in inferior or infero-lateral leads is associated with increased risk for life-threatening arrhythmias, termed early repolarization syndrome (ERS). Because accentuated J waves characterize both Brugada syndrome (BrS) and ERS, these syndromes have been grouped under the heading of J wave syndromes. BrS and ERS appear to share common ECG characteristics, clinical outcomes, risk factors as well as a common arrhythmic platform related to amplification of Ito-mediated J waves. However, they differ with respect to the magnitude and lead location of abnormal J waves and can be considered to represent a continuous spectrum of phenotypic expression. Recent studies support the hypothesis that BrS and ERS are caused by a preferential accentuation of the AP notch in right or left ventricular epicardium, respectively, and that this repolarization defect is accentuated by cholinergic agonists. Quinidine, cilostazol and isoproterenol exert ameliorative effects by reversing these repolarization abnormalities. Identifying subjects truly at risk is the challenge ahead. Our goal here is to review the clinical and genetic aspects as well as the cellular and molecular mechanisms underlying the J wave syndromes.

Background: An early repolarization pattern, characterized by an elevation of the QRS-ST junction (J-point) on 12-lead electrocardiography (ECG) is associated with cardiac and sudden death. However, little is known about the prognostic significance of J-point elevation for various disease-specific cardiovascular outcomes, including coronary artery disease (CAD). Methods and Results: To investigate the association between the presence of J-point elevation ≥0.1mV and various disease-specific cardiovascular outcomes, we conducted a 15-year prospective study in a representative general Japanese population of 7,630 individuals (41% men, mean age 52.4 years) who participated in the National Survey of Circulatory Disorders. Cox models were used to estimate the hazard ratios (HRs) adjusted for possible confounding factors. J-point elevation was present in 264 individuals (3.5%) and was associated with an increased risk of cardiac death (adjusted HR, 2.54; 95% confidence interval [CI] 1.40–4.58; P=0.002) and death from CAD (adjusted HR, 4.66; 95% CI 2.30–9.46; P

Introduction While BMI is known to affect ECG measurements, these effects have not been well characterized in young adults. Methods We retrospectively reviewed all ECGs performed in adults 18 to 35 years old at a single institution over a 30 year period. ECG measurements were derived electronically and stratified by WHO BMI category. Results A total of 55,218 ECGs were included. Increasing BMI led to increased P wave duration and decreasing P, R, and T wave axes. Additionally, while increasing BMI led to less R wave voltage, J point elevation, and T wave amplitude in patients with a BMI ≥ 18.5 kg/m2, there was also a decrease in the measured parameters in patients with a BMI Discussion BMI had significant effects on ECG measurements. For accurate assessment of ECGs, these data should be incorporated into established nomograms. Further investigation into the effects of BMI on the ECG is warranted.

We congratulate Nunn et al. ([1][1]) for their interesting report published recently in the Journal . They reported that J-point elevation in the inferolateral leads was more prevalent in the first-degree relatives of patients with sudden arrhythmic death syndrome (SADS) than in controls. They

Background— Early repolarization pattern is a common ECG finding characterized by J-point elevation and QRS notching or slurring in the inferior and/or lateral leads, yet little is known about its incidence and long-term prognosis in Asian populations. Methods and Results— We reviewed all the ECG records of the 5976 atomic-bomb survivors who were examined at least once during our biennial health examination in Nagasaki, Japan, between July 1958 and December 2004. We defined early repolarization pattern as ≥0.1-mV elevation of the J point or ST segment, with notching or slurring in at least 2 inferior and/or lateral leads. We assessed unexpected, cardiac, and all-cause death risk by Cox analysis. We identified 1429 early repolarization pattern cases (779 incident cases) during follow-up, yielding a positive rate of 23.9% and an incidence rate of 715 per 100 000 person-years. Early repolarization pattern had an elevated risk of unexpected death (hazard ratio, 1.83; 95% confidence interval, 1.12 to 2.97; P =0.02) and a decreased risk of cardiac (hazard ratio, 0.75; 95% confidence interval, 0.60 to 0.93; P P P =0.03), as was early repolarization pattern manifestation in both inferior and lateral leads (hazard ratio, 2.50; 95% confidence interval, 1.29 to 4.83; P Conclusions— Early repolarization pattern is associated with an elevated risk of unexpected death and a decreased risk of cardiac and all-cause death. Specific early repolarization pattern morphologies and location are associated with an adverse prognosis.