CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 7, August 2013
284
AFRICA
In individuals in whom ER was associated with a high rate
of cardiac death, J-point elevation
≥
0.2 mV was found to be
a strong predictor.
4
In the cohort studied by Tikkanen
et al
.,
inferior lead involvement was the sole risk marker of cardiac
and sudden arrhythmia deaths, whereas a rapidly ascending ST
segment after the J point seems to be a benign variant.
4,16
The
lateral leads were also incriminated in other studies.
9,17
Therefore,
given the definition of ER syndrome, which excludes the right
precordial leads, lead localisations have marginal significance.
Few trials have compared gender and origin of individuals
exhibiting ER.
26
In the ARIC study, whites and females were at
higher risk of SCD.
27
Two distinct patterns of J-point elevation are recognised. Patel
et al.
found the notching (a positive J-point deflection inscribed
on the S wave) pattern seemed to be of great value in the risk
stratification of individuals with ventricular vulnerability.
28
Maury
et al
.
29
found the same significance of the notching
pattern, and in his cohort from the city of Toulouse (France),
the long-term follow up of a general population has linked the
notching variant of ER to cardiac mortality.
Although the notched variant has been shown to have a
malignant outcome, the slurred (a smooth transition from QRS to
ST segment) variant of repolarisation may confer the same risk
as reported by Haruta
el al
.
17
Our study, although retrospective
in design, clearly emphasised a strong association between the
notching variant of ER and a history of syncope in index cases of
individuals presenting to the tertiary medical centres for cardiac
morbidity with a high prevalence of past history of syncope.
Study limitations
The strength of this study was that although ER is claimed
to be more prevalent in black American individuals,
1
to our
knowledge, the prevalence and significance of ER pattern in a
black African population has been understudied. However, some
limitations merit consideration. First, the study population was
a relatively small, select population of black African subjects
with cardiovascular morbidity. Second, although the patient
interrogation was blinded to the ECG results, the diagnosis
of syncope was made retrospectively and based on only the
patient’s interrogation. Therefore, it was difficult to distinguish
cardiogenic syncope among all causes. Third, this was a cross-
sectional rather than a cohort evaluation of ER. Therefore, we
could not test the relationship between ER and cardiovascular
morbidity and mortality, as was done by several other studies.
Conclusion
Early repolarisation is a common finding on ECGs of black
African individuals presenting for cardiovascular morbidity.
The notching rather than the slurring variant was significantly
associated with a past history of syncope. J-T-segment
morphology was not reported to be linked to syncope. The
prognostic significance of ER needs to be established in a
prospective fashion.
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