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Early repolarization

Andrew Krahn, MD
Manoj Obeyesekere, MBBS
Section Editor
Mark S Link, MD
Deputy Editor
Brian C Downey, MD, FACC


The term early repolarization (ER), also known as "J-waves" or "J-point elevation," has long been used to characterize a QRS-T variant on the electrocardiogram (ECG) [1]. Most literature defines ER as being present on the ECG when there is J-point elevation of ≥0.1 mV in two adjacent leads with either a slurred or notched morphology. Historically, ER has been considered a marker of good health because it is more prevalent in athletes, younger persons, and at slower heart rates [2,3]. However, numerous more recent reports have suggested an association between ER and an increased risk for arrhythmic death and idiopathic ventricular fibrillation (VF) [4-11].

While some level of increased risk of sudden cardiac death has been reported in persons with ER, the relatively high prevalence of the ER pattern in the general population (5 to 13 percent) in comparison to the incidence of idiopathic VF (approximately 10 cases per 100,000 population) means that the ER pattern will nearly always be an incidental ECG finding with no clinical implications. However, a primary arrhythmic disorder such as idiopathic VF due to ER is far more likely when associated with syncope or resuscitated sudden cardiac death in the absence of other etiologies. (See 'ER syndrome' below.)

This topic will review the genetics, prevalence, clinical manifestations, and diagnosis of ER and will present an approach to the management of patients with ER and idiopathic VF.


The definition of early repolarization (ER) on an electrocardiogram (ECG) is based on well-defined ECG findings (table 1). Although the 2013 HRS/EHRA/APHRS presented a definition (table 1), the 2016 AHA scientific Statement [12] highlights the lack of agreement across published studies pertaining to definition. A 2015 consensus document suggested reporting more detailed amplitudes of the J-wave including amplitudes corresponding to J-wave onset (Jo), J-wave peak (Jp), and J-wave termination (Jt), as well as durations D1 (Jo to Jp) and D2 (Jp to Jt), in relation to an end-QRS notch, and of Jp and Jt, as well as D2, in relation to an end-QRS slur [13]. The majority of publications at the present time merely adopt the amplitude of Jp as the reference point for measuring J-point elevation. The ST-segment should be regarded as horizontal or downward sloping if the amplitude of the ST-segment 100 ms after Jt (interval M) is less than or equal to the amplitude at Jt. The ST-segment should be regarded as upward sloping if the amplitude of the ST-segment 100 ms after Jt (interval M) is greater than the amplitude at Jt. However, duration measurements K, L, and M, each 100 ms, from Jo, Jp and Jt could be used in the measurement of the ST slope in the presence of a notch or duration measurements L or M, each 100 ms, used in the presence of an end-QRS slur with onset from Jp or Jt to measure slope, respectively.  

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Literature review current through: Oct 2017. | This topic last updated: Oct 10, 2016.
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