Electrocardiographic Early Repolarization in an Emergency Setting: The Subtleties of Electrocardiography

The electrocardiographic pattern of early repolarization (ER) is relatively common in the general population. In patients presenting to the emergency room with chest pain, it can be particularly challenging to distinguish ER from life-threatening subtle ST-segment elevation myocardial infarction (STEMI).A 37-year-old male presented to the emergency department with sudden-onset, severe, non-radiating, central chest pain. The ECG showed Q waves in the inferior leads and a widespread end-QRS notch with J-point elevation mimicking ST elevation in the inferior and lateral precordial leads. Initial cardiac biomarkers were within normal limits. Serial cardiac biomarkers were unremarkable. Echocardiography showed no wall motion abnormalities. A review of prior records from a month ago revealed a similar presentation with similar ECG findings when he underwent cardiac catheterization, revealing normal coronary arteries. Since the ECG was unchanged from the prior one with negative cardiac biomarkers and a negative angiographic study a month ago, no further ischemic risk stratification was indicated.Distinguishing ER from subtle STEMI in patients with acute chest pain can be challenging. A good clinical acumen, along with a comparison of prior ECGs, can aid in decision-making.