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Case 93


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A 28-year-old male was admitted at the emergency department for a 40-minute constricting chest pain which was not associated with breathing, physical activity or tenderness on palpation. He reported being at work when he experienced such pain and denied dyspnea or any other symptoms associated. He was previously healthy, did not take any medications and had no family history of coronary artery disease. He denied smoking, drinking alcohol or illicit drug use. He worked as hod carrier. On physical examination it was observed: BMI: 25, BP: 120/80 mmHg, PR: 88/min, RR: 20/min, normal breath sounds, regular heart rhythm and rate, normal heart sounds without murmurs and a soft, non-tender abdomen.

Based on the patient’s clinical history, we might assume that the electrocardiographic findings are compatible with:

a) Early repolarization


b) ST elevation acute coronary syndrome


c) Brugada syndrome


d) Acute pericarditis



– Early Ventricular Repolarization (EVR) is an electrocardiographic variation of the normal ventricular repolarization.

– It is considered as relevant part of the differential diagnoses of ST elevation, which include conditions such as myocardial infarction and pericarditis.

– EVR is considered benign, although some studies associate it with idiopathic ventricular fibrillation and sudden death in previously healthy patients.

– It is more prevalent in young males and athletes and is rare in the elderly.

– Electrocardiographic criteria include: J-wave elevation, sometimes seen as notching or slurring, upward concave ST-segment elevation of more than 0,1mV and increased T-waves amplitude in two contiguous chest leads. More commonly observed in V2-V5.

– Frequently, EVR is an incidental finding and does not require treatment.

– Patients who experience ventricular fibrillation should receive an implantable cardioverter-defibrillator to prevent sudden death.


– Benito B, Guasch E, Rivard L, Nattel S. Clinical and mechanistic issues in early repolarization of normal variants and lethal arrhythmia syndromes. J Am Coll Cardiol. 2010 Oct 5;56(15):1177-86.

– Bhatia A, Sra J, Akhtar M. Repolarization syndromes. Curr Probl Cardiol. 2012 Aug;37(8):317-62.

– Heng SJ, Clark EN, Macfarlane PW. End QRS notching or slurring in the electrocardiogram: influence on the definition of "early repolarization". J Am Coll Cardiol. 2012 Sep 4;60(10):947-8.

– Riera AR, Uchida AH, Schapachnik E, Dubner S, Zhang L, Celso Ferreira Filho, Ferreira C. Early repolarization variant: epidemiological aspects, mechanism, and differential diagnosis. Cardiol J. 2008;15(1):4-16.

– UPTODATE:  Andrew Krahn, MD; Manoj Obeyesekere, MBBS. Early repolarization


Daniel Moore Freitas Palhares – 5th year medical student of UFMG School of Medicine.

E-mail: danielmoore2[at]


Professor Milena Soriano Marcolino – member of the Department of Internal Medicine (UFMG School of Medicine).

E-mail: milenamarc[at]


Emília Valle, Fernanda Foureaux and professor Viviane Parisotto.

Translated by

Lucas Resende Lucinda, 5th year medical student of UFMG School of Medicine.
E-mail: lucasresendebh[at]

Juan Bernard, 5th year medical student of UFMG School of Medicine.
E-mail: juanbernard[at]


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