Yonsei Med J.  2014 Jul;55(4):928-936. 10.3349/ymj.2014.55.4.928.

Early Repolarization and Myocardial Scar Predict Poorest Prognosis in Patients with Coronary Artery Disease

• Lee HY
• Mun HS
• Wi J
• Uhm JS
• Shim J
• Kim JY
• Pak HN
• Lee MH
• Joung B

• KMID: 2130816
• DOI: http://doi.org/10.3349/ymj.2014.55.4.928

Abstract

PURPOSE
Recent studies show positive association of early repolarization (ER) with the risk of life-threatening arrhythmias in patients with coronary artery disease (CAD). This study was to investigate the relationships of ER with myocardial scarring and prognosis in patients with CAD.
MATERIALS AND METHODS
Of 570 consecutive CAD patients, patients with and without ER were assigned to ER group (n=139) and no ER group (n=431), respectively. Myocardial scar was evaluated using cardiac single-photon emission computed tomography.
RESULTS
ER group had previous history of myocardial infarction (33% vs. 15%, p<0.001) and lower left ventricular ejection fraction (57+/-13% vs. 62+/-13%, p<0.001) more frequently than no-ER group. While 74 (53%) patients in ER group had myocardial scar, only 121 (28%) patients had in no-ER group (p<0.001). During follow up, 9 (7%) and 4 (0.9%) patients had cardiac events in ER and no-ER group, respectively (p=0.001). All patients with cardiac events had ER in inferior leads and horizontal/descending ST-segment. Patients with both ER in inferior leads and horizontal/descending ST variant and scar had an increased adjusted hazard ratio of cardiac events (hazard ratio 16.0; 95% confidence interval: 4.1 to 55.8; p<0.001).
CONCLUSION
ER in inferior leads with a horizontal/descending ST variant was associated with increased risk of cardiac events. These findings suggest that ER in patients with CAD may be related to myocardial scar rather than pure ion channel problem.

Keyword

Electrocardiography; coronary artery disease; sudden cardiac death; cardiac arrhythmia

MeSH Terms

Aged
Arrhythmias, Cardiac/physiopathology
Cicatrix/*physiopathology
Coronary Artery Disease/*pathology/*physiopathology
Death, Sudden, Cardiac/pathology
Female
Heart Conduction System/abnormalities/physiopathology
Humans
Male
Middle Aged
Myocardium/*pathology
Prognosis

Figure

• 

  Fig. 1 Classification of ECG patterns. (A) Horizontal/descending ST-segment patterns. The patient presented horizontal/descending ER in leads II, III, and aVF (arrows) at one month after PCI (A-1) and persisted for 2 years after PCI (A-2). (B) Concave/rapidly ascending ST-segment patterns. The patient presented concave/rapidly ascending ER in lateral leads one month after CABG (B-1). These ER resolved after one month (B-2). ECG, electrocardiography; ER, early repolarization.

• 

  Fig. 2 Early repolarization in a 64-year-old male patient with history of ST-elevation, anterior wall myocardial infarction and scar. (A) 12-lead ECG at one year after MI showed prominent J-point elevations (arrows) in leads of II, III and aVF. (B) Cardiac SPECT at one year after MI showed irreversible perfusion defect in the anterior portion of mid to apex of the heart. (C) Coronary angiography showed near-total occlusion of the left anterior descending artery. MI, myocardial infarction; SPECT, single-photon emission computed tomography; ECG, electrocardiography.

• 

  Fig. 3 Findings in a 59-year-old patient with CAD but without ER and without myocardial scar formation. (A) ER pattern was not observed. (B) No defect detected by SPECT. (C) Revascularization of the critical stenosis of left anterior descending artery. CAD, coronary artery disease; ER, early repolarization; SPECT, single-photon emission computed tomography.

• 

  Fig. 4 The Kaplan-Meier survival curves for cardiac events according to the presence of myocardial scarring and J wave. The patients with J wave and myocardial scar had lowest cumulative event-free survival (log rank p<0.001).

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