Benign Versus Malignant Early Repolarization Patterns

  • Raphael Rosso
  • Sami Viskin


Distinguishing the “benign” from the “malignant” patterns of early repolarization is of outmost importance because the former electrocardiogram (ECG) pattern is frequently observed in healthy individuals, whereas the latter, far more rarely, is associated with sudden death from idiopathic ventricular fibrillation (VF). It is important to analyze the three components of the early repolarization ECG pattern, that is, the J-wave proper, the ST-segment, and the ensuing T-waves. T-waves of higher amplitude and longer duration, ST-segments that are horizontal or descending (as opposed to ascending ST-segment), and low-amplitude T-waves correlate with increased risk of idiopathic VF. However, there is too much overlapping between the values of the two groups to allow for reliable diagnosis in the absence of symptoms (except for the rare “monstrous” J-waves).


Early repolarization Electrocardiogram Ventricular fibrillation 


  1. 1.
    Viskin S, Rosso R, Halkin A. Making sense of early repolarization. Heart Rhythm. 2012;9(4):566–8.CrossRefGoogle Scholar
  2. 2.
    Rosso R, Adler A, Halkin A, Viskin S. Risk of sudden death among young individuals with J waves and early repolarization: putting the evidence into perspective. Heart Rhythm. 2011;8(6):923–9.CrossRefGoogle Scholar
  3. 3.
    Adler A, Rosso R, Viskin D, Halkin A, Viskin S. What do we know about the “malignant form” of early repolarization? J Am Coll Cardiol. 2013;62(10):863–8.CrossRefGoogle Scholar
  4. 4.
    Ezaki K, Nakagawa M, Taniguchi Y, Nagano Y, Teshima Y, Yufu K, et al. Gender differences in the ST segment: effect of androgen-deprivation therapy and possible role of testosterone. Circ J. 2010;74(11):2448–54.CrossRefGoogle Scholar
  5. 5.
    Walsh JA 3rd, Ilkhanoff L, Soliman EZ, Prineas R, Liu K, Ning H, et al. Natural history of the early repolarization pattern in a biracial cohort: CARDIA (Coronary Artery Risk Development in Young Adults) Study. J Am Coll Cardiol. 2013;61(8):863–9.CrossRefGoogle Scholar
  6. 6.
    Panicker GK, Manohar D, Karnad DR, Salvi V, Kothari S, Lokhandwala Y. Early repolarization and short QT interval in healthy subjects. Heart Rhythm. 2012;9(8):1265–71.CrossRefGoogle Scholar
  7. 7.
    Tikkanen JT, Junttila MJ, Anttonen O, Aro AL, Luttinen S, Kerola T, et al. Early repolarization: electrocardiographic phenotypes associated with favorable long-term outcome. Circulation. 2011;123(23):2666–73.CrossRefGoogle Scholar
  8. 8.
    Noseworthy PA, Weiner R, Kim J, Keelara V, Wang F, Berkstresser B, et al. Early repolarization pattern in competitive athletes: clinical correlates and the effects of exercise training. Circ Arrhythm Electrophysiol. 2011;4(4):432–40.CrossRefGoogle Scholar
  9. 9.
    Perez MV, Uberoi A, Jain NA, Ashley E, Turakhia MP, Froelicher V. The prognostic value of early repolarization with ST-segment elevation in African Americans. Heart Rhythm. 2012;9(4):558–65.CrossRefGoogle Scholar
  10. 10.
    Haissaguerre M, Derval N, Sacher F, Jesel L, Deisenhofer I, de Roy L, et al. Sudden cardiac arrest associated with early repolarization. N Engl J Med. 2008;358(19):2016–23.CrossRefGoogle Scholar
  11. 11.
    Rosso R, Kogan E, Belhassen B, Rozovski U, Scheinman MM, Zeltser D, et al. J-point elevation in survivors of primary ventricular fibrillation and matched control subjects incidence and clinical significance. J Am Coll Cardiol. 2008;52(15):1231–8.CrossRefGoogle Scholar
  12. 12.
    Kim SH, Kim do Y, Kim HJ, Jung SM, Han SW, Suh SY, et al. Early repolarization with horizontal ST segment may be associated with aborted sudden cardiac arrest: a retrospective case control study. BMC Cardiovasc Disord. 2012;12:122.CrossRefGoogle Scholar
  13. 13.
    Talib AK, Sato N, Asanome A, Myojo T, Nishiura T, Yamaki M, et al. Impaired ventricular repolarization dynamics in patients with early repolarization syndrome. J Cardiovasc Electrophysiol. 2013;24(5):556–61.CrossRefGoogle Scholar
  14. 14.
    Pargaonkar VS, Perez MV, Jindal A, Mathur MB, Myers J, Froelicher VF. Long-term prognosis of early repolarization with J-wave and QRS slur patterns on the resting electrocardiogram: a Cohort Study. Ann Intern Med. 2015;163(10):747–55.CrossRefGoogle Scholar
  15. 15.
    Macfarlane PW, Antzelevitch C, Haissaguerre M, Huikuri HV, Potse M, Rosso R, et al. The early repolarization pattern: a consensus paper. J Am Coll Cardiol. 2015;66(4):470–7.CrossRefGoogle Scholar
  16. 16.
    Surawicz B, Macfarlane PW. Inappropriate and confusing electrocardiographic terms: J-wave syndromes and early repolarization. J Am Coll Cardiol. 2011;57(15):1584–6.CrossRefGoogle Scholar
  17. 17.
    Roten L, Derval N, Maury P, Mahida S, Pascale P, Leenhardt A, et al. Benign vs. malignant inferolateral early repolarization: focus on the T wave. Heart Rhythm. 2016;13(4):894–902.CrossRefGoogle Scholar
  18. 18.
    Viskin S, Havakuk O, Antzelevitch C, Rosso R. Malignant early repolarization: It’s the T-wave, stupid. Heart Rhythm. 2016;13(4):903–4.CrossRefGoogle Scholar
  19. 19.
    Viskin S, Rosso R. J-wave syndromes. In: Zipes DP, Jalife J, Stevenson WG, editors. Cardiac electrophysiology: from cell to bedside. 7th ed: Philadelphia: Elsevier; 2017.CrossRefGoogle Scholar
  20. 20.
    Osborn JJ. Experimental hypothermia; respiratory and blood pH changes in relation to cardiac function. Am J Phys. 1953;175(3):389–98.CrossRefGoogle Scholar
  21. 21.
    Johnson P, Lesage A, Floyd WL, Young WG Jr, Sealy WC. Prevention of ventricular fibrillation during profound hypothermia by quinidine. Ann Surg. 1960;151:490–5.CrossRefGoogle Scholar
  22. 22.
    Fish JM, Antzelevitch C. Link between hypothermia and the Brugada syndrome. J Cardiovasc Electrophysiol. 2004;15(8):942–4.CrossRefGoogle Scholar
  23. 23.
    Gurabi Z, Koncz I, Patocskai B, Nesterenko VV, Antzelevitch C. Cellular mechanism underlying hypothermia-induced ventricular tachycardia/ventricular fibrillation in the setting of early repolarization and the protective effect of quinidine, cilostazol, and milrinone. Circ Arrhythm Electrophysiol. 2014;7(1):134–42.CrossRefGoogle Scholar
  24. 24.
    Bastiaenen R, Hedley PL, Christiansen M, Behr ER. Therapeutic hypothermia and ventricular fibrillation storm in early repolarization syndrome. Heart Rhythm. 2010;7(6):832–4.CrossRefGoogle Scholar
  25. 25.
    Federman NJ, Mechulan A, Klein GJ, Krahn AD. Ventricular fibrillation induced by spontaneous hypothermia in a patient with early repolarization syndrome. J Cardiovasc Electrophysiol. 2013;24(5):586–8.CrossRefGoogle Scholar
  26. 26.
    Kanna B, Wani S. Giant J wave on 12-lead electrocardiogram in hypothermia. Ann Noninvasive Electrocardiol. 2003;8(3):262–5.CrossRefGoogle Scholar
  27. 27.
    Cristoforetti Y, Biasco L, Giustetto C, De Backer O, Castagno D, Astegiano P, et al. J-wave duration and slope as potential tools to discriminate between benign and malignant early repolarization. Heart Rhythm. 2016;13(3):806–11.CrossRefGoogle Scholar
  28. 28.
    Aizawa Y, Takatsuki S, Nishiyama T, Kimura T, Kohsaka S, Kaneko Y, et al. Tachycardia-induced J-wave changes in patients with and without idiopathic ventricular fibrillation. Circ Arrhythm Electrophysiol. 2017;10(7):pii:e005214.CrossRefGoogle Scholar
  29. 29.
    Rosso R, Glikson E, Belhassen B, Katz A, Halkin A, Steinvil A, et al. Distinguishing “benign” from “malignant early repolarization”: the value of the ST-segment morphology. Heart Rhythm. 2012;9(2):225–9.CrossRefGoogle Scholar
  30. 30.
    Cappato R, Furlanello F, Giovinazzo V, Infusino T, Lupo P, Pittalis M, et al. J wave, QRS slurring, and ST elevation in athletes with cardiac arrest in the absence of heart disease: marker of risk or innocent bystander? Circ Arrhythm Electrophysiol. 2010;3(4):305–11.CrossRefGoogle Scholar
  31. 31.
    Zhang J, Hocini M, Strom M, Cuculich PS, Cooper DH, Sacher F, et al. The electrophysiological substrate of early repolarization syndrome: noninvasive mapping in patients. JACC Clin Electrophysiol. 2017;3(8):894–904.CrossRefGoogle Scholar
  32. 32.
    Haissaguerre M, et al. Ventricular fibrillation with prominent early repolarization associated with a rare variant of KCNJ8/KATP channel. J Cardiovasc Elecrophysiol. 2009;20:93.CrossRefGoogle Scholar
  33. 33.
    Aizawa Y, et al. Dynamicity of the J-wave in idiopathic ventricular fibrillation with a special reference to pause-dependent augmentation of the J-wave. JACC. 2012;59:1948.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Raphael Rosso
    • 1
  • Sami Viskin
    • 1
  1. 1.Department of CardiologyTel Aviv Medical Center and Sackler School of Medicine, Tel Aviv UniversityTel Aviv-YafoIsrael

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