This is an ECG of a 25-year-old, recorded in master health check-up.
It was reported as ERS pattern of concern. When he went for an expert opinion, he was suggested to understand, there is a small risk of SCD. That’s it, the panic has set in already, which got amplified in the following conversation..
How small is the risk,? he wanted to know.
Yours’ is possibly an intermediate risk.
Intermediate means what? Do I have any genetic or EP studies to predict the risk accurately?
Sorry, we have some gene mapping but all primitive. We aren’t sure. But keep calm, nothing will happen.
Do I need to screen my parents ?
No, but if you are anxious you may take an ECG for them
If they also show the same pattern, it becomes more significant, is it not doctor?
Hmm yes, maybe.
This is a brief story of this young man, whose life was made miserable by the apparently widening knowledge base of cardiologists
ERS: A brief opinionated review
The term early repolarisation in ECG is used for more than half a century. It’s about the behavior of the Ito channel, at the left shoulder of the action potential, when phase 0 hands over the baton to 1, at the onset of repolarisation. The problem is the rapidity with which K+ exit from the cell, which is heavily influenced by genetic control. Not only that, the ratio of epi vs endocardial density of these Ito channels determines, the timing, magnitude, and shape, of the J point.
It would be mind-boggling to know the prevalence of such ERS patterns in the general population. One estimate suggests it could be anywhere between 3 to 13 % depending upon the criteria used. Let us assume the mean as 5 %. Then, it would be 30 crores of human beings in our habitat show this ECG pattern. If applied, in my city Chennai alone 5 lakh people could carry this tag.
While it is true, some forms of ERS and J wave syndrome can be markers of serious ventricular arrhythmias, either spontaneous or at times of Ischemia. Currently, It has become a fad, in cardiology academic circles*, to propagate the idea that ERS is no longer a benign condition. This is not acceptable at any degree of cognition. This happened mainly after few studies in powerful journals created some alarmist views. (*Maybe there is a bit of truth there. I still have doubts about whether we interpreted the Michel Haïssaguerre study properly)
Final message
ERS is a widely prevalent normal ECG variation with a minuscule risk. High-risk subsets need to be screened only if the J waves encroach and spill dangerously into the ST segment as well. Of course, this pattern is of serious concern if there is a family history of young SCDs has occurred.
The purpose of scientific knowledge in medicine is to reduce suffering. I wish, at no point in time, it can increase anxiety. We need to introspect, whether to report such ECG entities at all. In the name of patient empowerment, let us not create Iatrogenic, knowledge-induced panic. Labeling a person with a fearful entity and then keep reassuring and asking him to forget, is not a fun exercise. Meanwhile, indiscriminate reporting of such mass ECG phenomena can potentially turn out to be a commercial game.
For advanced readers: Important queries for fellows
- Why Inferior lead ERS is more risk prone than lateral?
- What happens to ERS pattern during exercise?
- What is the genetic and structural overlap between ERS and Brugada?
- If ERS develops unstable angina will the ST elevate or normalize or depress?
- How will be the RVOT and RV wall motion in ERS?
Reference
Here is a good review of this topic by
1.Dr. KK Sethi et al.Indian Heart Journal. 2014
2. Hanboly NH. Haissaguerre syndrome: The gray area still exists. Nig J Cardiol 2017;14:59-64.
Dr.S.Venkatesan MD 