Nonischemic ST-Segment Elevation

Scenario: This is a resting 12-lead ECG obtained in a 47-year-old African American male patient presenting to the emergency department with complaints of atypical chest pain. The patient has no prior history of heart disease but is a smoker and has a sedentary lifestyle.Interpretation: Sinus rhythm, left ventricular hypertrophy (LVH), and ST-segment elevation in the precordial leads due to early repolarization syndrome (ERS).Although the prevalence of ERS is low (1% to 2%), it is not uncommon to see this ECG pattern in patients presenting to acute care facilities with symptoms suggestive of acute myocardial infarction (MI). ERS is considered to be an idiopathic yet benign ECG pattern. One feature of ERS is ST-segment elevation; hence, it is possible to interpret this ECG pattern as an acute MI. It is important to distinguish these 2 ECG patterns to avoid misdiagnosis. The classic ECG pattern of ERS includes tall QRS voltage, a notch or slur at the J-point (the junction that marks the end of the QRS complex and the start of the ST segment) sometimes referred to as a “fishhook” pattern (seen above in leads V3 and V4), and a concave ST segment (seen in leads V3-V6). The T waves are often tall with a positive deflection. The mid- precordial leads V2 to V4 typically show the greatest ST- segment elevation, and reciprocal ST-segment depression may be seen in lead aVR. The ST-segment pattern of ERS may also be seen in the limb leads.Early repolarization syndrome is more often seen in the young, in men, in athletes, and in patients with cocaine use or structural defects of the myocardium. In some young black men, the ST-segment pattern of ERS may be seen along with T-wave inversion.This patient also meets criteria for LVH (ie, S wave + R wave in V5>35 millimeters).Because this patient presented with chest pain, anticipate ruling him out for acute MI (ie, cardiac enzymes, continuous bedside ECG monitoring, echocardiogram). A careful history of cardiac symptoms should be obtained. Because this patient has LVH, he should be evaluated for hypertension. Lastly, because he has modifiable risk factors for heart disease, education regarding smoking cessation and exercise should be provided.