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Robert Sarlay, Jr., MD, MPH, FACEP
Lt Col, USAF, MC, FS
USAF School of Aerospace Medicine
WPAFB, OH
RAM 2013
Early Repolarization in the Early Repolarization in the Aviator Aviator
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Disclosure InformationDisclosure Information8484thth Annual Scientific Meeting Annual Scientific Meeting
Dr. Robert Sarlay, Jr.Dr. Robert Sarlay, Jr.
I have no financial relationships to disclose.
I will not discuss off-label use and/or investigational use in my presentation
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• Principal Investigator• Lt Col Robert Sarlay, Jr.
• Preceptor• Maj Eddie Davenport
• Secondary Investigators• Mr. Jared Haynes• Ms. Rosa Alvarado
Preceptor/InvestigatorsPreceptor/Investigators
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• Early repolarization pattern (ERP) more common:• Young• Athletes
• ERP tends to resolve over time• Prior research often based on single ECG
prevalence studies• ERP is considered benign• Recent literature contradicts this consensus
• Pro-arrhythmic trait?• Increased incidence sudden cardiac death
Background / Literature Background / Literature ReviewReview
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• Prevalence General Population• 1-5% prevalence depending on the study• Eastaugh (1989) – Review article first described 1936
young military recruits, 1-2% had ERP• Lanza et al. (2012) – Prospective study of 4176 subjects
presenting to hospital without heart disease found 84 (2.0%) had ERP
• Tikkanen et al. (2009) – 10,864 patients from general population, 630 had ERP (5.8%)
• Noseworthy et al. (2011) – ERP 243 of 3,955 (6.1%) Framingham Heart Study and 180 of 5,489 (3.3%) Health 2000 Survey
Background / Literature Background / Literature ReviewReview
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• Prevalence in Athletes• Tanguturi et al. (2012) – ERP in athletes range from 20 to 90%• Noseworthy et al. (2011) – Cross-sectional cohort of 879
college athletes, 25.1% had ERP; exercise training led to increases in prevalence
• Prevalence in Aircrew• Boos et al. (2012) – Reported 11.8% of 868 healthy aircrew had
ERP [average age 39.6, 95.4% male]
• Natural History• Adhikarla (2011) – 29,281 patients found 479 with ERP,
analyzed 244 found that 10 years later 68% no longer had ERP on ECG, at time largest serial comparison
• Other studies have reported decreasing prevalence with age
Background / Literature Background / Literature ReviewReview
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• USAF ECG Library• All cardiac data• 281,737 aviators• 1950-2011 inclusive (60+ years)• Age 17 to 65• 1.2 million ECG studies
• Inclusion Criteria for ERP• >0.1 mv J-point elevation in >2 inferior or
lateral leads (II, III, AVF; I, AVL, V4-6)
MethodsMethods
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• Queried database for all ERP ECGs• Queried any ERP subject for any normal
ECG• Divided results into categories
• Group 1 – Always had ERP• Group 2 – ERP then normal • Group 3 – Normal then ERP• Group 4 – Variable
MethodsMethods
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• SAS software used• Descriptive statistics • Bonferroni test used to compare:
• Group 2 – ERP to normal• Group 3 – Normal to ERP
MethodsMethods
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• 85,642 ECGs either normal or ERP pattern• Total 41,327 ECGs with ERP pattern• Unique 27,797 with ERP pattern • Groups:
1) Always ERP = 1570 / 952 complete
2) ERP Normal = 12,432 / 5,636 complete
3) Normal ERP = 15,562 / 6,697 complete
4) Variable = 56,078 / 14,516 complete
ResultsResults
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ResultsResults
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ResultsResults
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• Prevalence• 9.9% aviators had ERP
• Natural History• 20.3% lost ERP over time• 27.5% retained ERP over time• 52.2% variable
ResultsResults
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Mean Standard Deviation
Skewness Range Min/Max
Age (yr) 28.34 7.7 0.71 42 17 / 59
Height (in) 70.73 2.6 -0.02 19 60 / 79
Weight (lb) 169.9 20.2 0.31 149 106 / 255
Systolic 116.4 10.3 0.05 80 80 / 160
Diastolic 73.3 8.5 -0.04 56 40 / 96
ResultsResultsGroup 1 – Always ERPGroup 1 – Always ERP
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Mean Standard Deviation
Skewness Range Min/Max
Age (yr) 34.2 6.7 -0.03 46 17 / 63
Height (in) 70.7 2.6 -0.15 20 58 / 78
Weight (lb) 178 22.6 0.46 209 86 / 295
Systolic 118.8 11.4 0.50 92 88 / 180
Diastolic 74.9 8.7 0.07 110 40 / 150
Time Between
6.9 5.3 0.78 28.4 0 / 28.4
ResultsResultsGroup 2 – ERP then Normal Group 2 – ERP then Normal
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Mean Standard Deviation
Skewness Range Min/Max
Age (yr) 37 7.6 -0.35 46 19 / 65
Height (in) 70.5 2.6 -0.53 37 43 / 80
Weight (lb) 174.6 20.5 0.26 165 99 / 264
Systolic 116.9 10.7 0.43 98 82 / 180
Diastolic 74.7 8.2 -0.06 61 49 / 110
Time Between
10.0 6.9 0.63 87.9 0 / 87.9
ResultsResultsGroup 3 – Normal then ERPGroup 3 – Normal then ERP
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• Statistical difference between groups• Age• Weight• Systolic BP• Time to change
• No statistical difference between groups• Height• Diastolic BP
ResultsResultsCompare Group 2 to 3Compare Group 2 to 3
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• USAF aviators have higher prevalence of ERP than general population
• ? Healthy heart as with athletes
• Prevalence similar to prior aviation studies 9.9% vs. 11.8%
• Retention of ERP similar to prior studies 27.5% vs. 32%
DiscussionDiscussion
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• Not all ECGs reviewed• Only 51 females identified• Sampling bias because of required ECGs
for initial flying physical and at age 35
LimitationsLimitations
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• Analysis of large database with serial ECGs over time was consistent with prior research in regard to the natural history and prevalence of ERP
ConclusionConclusion
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• Correlate ERP with outcome data to determine if aviators are at increased risk of cardiovascular events or increased mortality
• Further analyze the variable group with regard to consistency of diagnosis
• Prospectively follow ERP diagnosis over time
Future ResearchFuture Research
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• Adhikarla C, Boga M, Wood AD, et al. Natural history of the electrocardiographic pattern of early repolarization in ambulatory patients. Am J Cardiol 2011;108:1831-5.
• Boineau J P. The early repolarization variant --normal or marker of heart disease in certain subjects. J Electrocardiol 2007;40:3.e11-6.
• Boos CJ, Jamil Y, Park M, et al. Electrocardiographic abnormalities in medically screened military aircrew. Aviat Space Environ Med 2012;83:1055-9.
• Eastaugh JA. The early repolarization syndrome. J Emerg Med 1989;7:257-62.• Haïssaguerre M, Derval N, Sacher F, et al. Sudden cardiac arrest associated with early
repolarization. N Engl J Med 2008;358:2016-23.• Haruta D, Matsuo K, Tsuneto A, et al. Incidence and prognostic value of early repolarization
pattern in the 12-lead electrocardiogram. Circulation 2011;123:2931-7.• Junttila MJ, Sager S, Tikkanen J, et al. Clinical significance of variants of J-points and J-waves:
early repolarization patterns and risk. Eur Heart J 2012;33:2639-44.• Lanza GA, Mollo R, Cosenza A, et al. Prevalence and clinical correlates of early repolarization
and J wave in a large cohort of subjects without overt heart disease. J Electrocardiol 2012;45:404-10.
BibliographyBibliography
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• Noseworthy PA, Tikkanen JT, Porthan K, et al. The early repolarization pattern in the general population: clinical correlates and heritability. J Am Coll Cardiol 2011;57:2284-9.
• Noseworthy PA, Weiner R, Kim J, et al. Early repolarization pattern in competitive athletes: clinical correlates and the effects of exercise training. Circ Arrhythm Electrophysiol 2011;4:432-40.
• Nunn LM, Bhar-Amato J, Lowe MD, et al. Prevalence of J-point elevation in sudden arrhythmic death syndrome families. J Am Coll Cardiol 2011;58:286-90.
• Rollin A, Maury P, Bongard V, et al. Prevalence, prognosis, and identification of the malignant form of early repolarization pattern in a population-based study. Am J Cardiol 2012;110:1302-8.
• Stern S. Clinical aspects of the early repolarization syndrome: a 2011 update. Ann Noninvasive Electrocardiol 2011;16:192-5.
• Tanguturi, VK, Noseworthy PA, Newton-Cheh C, et al. The electrocardiographic early repolarization pattern in athletes: normal variant or sudden death risk factor? Sports Med 2012;42:359-66.
• Tikkanen JT, Anttonen O, Junttila MJ, et al. Long-term outcome associated with early repolarization on electrocardiography. N Engl J Med 2009;361:2529-37.
BibliographyBibliography
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Questions?Questions?