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Association of Early Repolarization Pattern on ECG with Risk of Cardiac and All-Cause Mortality: A Population-Based Prospective Cohort Study (MONICA/KORA)
Open accessAbstract
BACKGROUND: Early repolarization pattern (ERP) on electrocardiogram was associated with idiopathic ventricular fibrillation and sudden cardiac arrest in a case-control study and with cardiovascular mortality in a Finnish community-based sample. We sought to determine ERP prevalence and its association with cardiac and all-cause mortality in a large, prospective, population-based case-cohort study (Monitoring of Cardiovascular Diseases and Conditions [MONICA]/KORA [Cooperative Health Research in the Region of Augsburg]) comprised of individuals of Central-European descent. METHODS AND FINDINGS: Electrocardiograms of 1,945 participants aged 35-74 y, representing a source population of 6,213 individuals, were analyzed applying a case-cohort design. Mean follow-up was 18.9 y. Cause of death was ascertained by the 9th revision of the International Classification of Disease (ICD-9) codes as documented in death certificates. ERP-attributable effects on mortality were determined by a weighted Cox proportional hazard model adjusted for covariables. Prevalence of ERP was 13.1% in our study. ERP was associated with cardiac and all-cause mortality, most pronounced in those of younger age and male sex; a clear ERP-age interaction was detected (p = 0.005). Age-stratified analyses showed hazard ratios (HRs) for cardiac mortality of 1.96 (95% confidence interval [CI] 1.05-3.68, p = 0.035) for both sexes and 2.65 (95% CI 1.21-5.83, p = 0.015) for men between 35-54 y. An inferior localization of ERP further increased ERP-attributable cardiac mortality to HRs of 3.15 (95% CI 1.58-6.28, p = 0.001) for both sexes and to 4.27 (95% CI 1.90-9.61, p<0.001) for men between 35-54 y. HRs for all-cause mortality were weaker but reached significance. CONCLUSIONS: We found a high prevalence of ERP in our population-based cohort of middle-aged individuals. ERP was associated with about a 2- to 4-fold increased risk of cardiac mortality in individuals between 35 and 54 y. An inferior localization of ERP was associated with a particularly increased risk. Please see later in the article for the Editors' Summary.
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“Furthermore, it has been shown in population-based studies to be associated with increased risk of cardiac death (352,353,355–357).”
From 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope (2017) · cites this paper as [357]
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Citations
Cites
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BackgroundSudden Cardiac Arrest Associated with Early Repolarization
Haïssaguerre, M., Derval, N., Sacher, F., Jesel, L., Deisenhofer, I., de Roy, L., Pasquié, J.-L., Nogami, A., Babuty, D., Yli-Mayry, S., et al. (2008) · New England Journal of Medicine · doi:10.1056/nejmoa071968 · Cited by 1,449 · cited 4×
“However, this judgment was seriously questioned by both (1) a study, in which ERP was found to be a clinically relevant ECG signature, and possibly a marker of SCD, in the evaluation of unexplained syncope or idiopathic ventricular fibrillation in patients without structural heart disease [7], and (2) the recent repor…”
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Long-Term Outcome Associated with Early Repolarization on Electrocardiography
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“. Recently, a community-based investigation of Finnish individuals demonstrated a slightly increased cardiovascular mortality associated with ERP”
BackgroundProlonged QTc Interval and Risk of Sudden Cardiac Death in a Population of Older Adults
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“SCD occurs in approximately 50% of all cardiovascular deaths [10].”
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“As seen for a number of other ECG signatures, for example QT- or PR-interval [27–29], among other factors, there might also be a heritable component, explaining part of the variable occurrence of ERP in the population or the degree of arrhythmogenicity.”
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“Following the case-cohort design [13,14], a representative random sample of the entire source population was drawn (referred to below as the subcohort), stratified by sex and survey as described elsewhere [15–17].”
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Pfeufer, A., Sanna, S., Arking, D. E., Müller‐Nurasyid, M., Gateva, V., Fuchsberger, C., Ehret, G., Orrù, M., Pattaro, C., Köttgen, A., et al. (2009) · Nature Genetics · doi:10.1038/ng.362 · Cited by 385 · cited 1×
“As seen for a number of other ECG signatures, for example QT- or PR-interval [27–29], among other factors, there might also be a heritable component, explaining part of the variable occurrence of ERP in the population or the degree of arrhythmogenicity.”
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ResultThe early repolarization normal variant electrocardiogram: correlates and consequences
Klatsky, A. L., Oehm, R., Cooper, R. A., Udaltsova, N. V., & Armstrong, M. A. (2003) · The American Journal of Medicine · doi:10.1016/s0002-9343(03)00355-3 · Cited by 327
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“With regard to the clinical impact of ERP, a careful interpretation is required. Younger males (35–54 y) in our study appear to bear the highest risk. However, the maximum risk attributed to ERP might be overestimated because of low incidence of cardiac deaths in the younger age groups. ERP is associated with a 2–4-fo…”
ResultInfluentialCardiological assessment of first-degree relatives in sudden arrhythmic death syndrome
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“Against the general notion that SUD is more common in men—autopsy series reported 63%–68% males [22,23]—the Edwards Registry of Cardiovascular Death found a clear female predominance for SUD (32% and 24% for women and men, respectively).”
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The normal RS-T segment elevation variant∗
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Metadata
- Authors
- Sinner, M. F., Reinhard, W., Müller, M., Beckmann, B.-M., Martens, E., Perz, S., Pfeufer, A., Winogradow, J., Stark, K., Meisinger, C., Wichmann, H.-E., Peters, A., Riegger, G. A. J., Steinbeck, G., Hengstenberg, C., & Kääb, S.
- Affiliations
- Ludwig-Maximilians-Universität München (DE)
- University Hospital Regensburg (DE)
- Helmholtz Munich (DE)
- Corresponding author
- Kääb, Stefan
- ORCID
- Venue
- PLoS Medicine
- Publisher
- Public Library of Science (PLoS)
- Published
- 2010-07-27
- Volume
- 7
- Issue
- 7
- Pages
- e1000314
- ISSN
- 1549-1277 (ISSN-L)
- 1549-1676
- PMC
- PMC2910598
- OpenAlex
- W2133142369
- Cited by
- 282
- References
- 35
- Citations by year
- 2026: 7 · 2025: 6 · 2024: 4 · 2023: 7 · 2022: 12 · 2021: 6 · 2020: 11 · 2019: 18 · 2018: 14 · 2017: 25 · 2016: 32 · 2015: 26 · 2014: 19 · 2013: 39 · 2012: 24
- FWCI
- 20.87
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PLoS Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Open access LMU (Ludwid Maxmilian's Universitat Munchen) (submittedVersion)
- Figshare (submittedVersion, cc-by)
- mediaTUM (Technical University of Munich) (submittedVersion)
- Site cant be reached (submittedVersion, cc-by)
- OPUS (Augsburg University) (submittedVersion, cc-by)
- Funders
- Deutsche Forschungsgemeinschaft
- Fondation Leducq (01GS0838)
- Bundesministerium für Bildung und Forschung (01GS0499, 01GS0838)
- Münchner Zentrum für Gesundheitswissenschaften
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Effects of Exercise
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Keywords
- early repolarization, electrocardiogram, cardiac mortality, all-cause mortality, sudden cardiac death, age-stratified risk, sex differences, middle-aged adults, cardiovascular risk factors, Central European population, idiopathic ventricular fibrillation, sudden cardiac arrest, cardiovascular disease monitoring, cardiovascular disease prevention, cardiovascular disease treatment
- MeSH terms
- Adult, Aged, Cause of Death, Electrocardiography, Female, Germany, Heart Diseases, Humans, Male, Middle Aged, Population, Population Surveillance, Prospective Studies, Risk, Time Factors, Cohort Studies, Case-Control Studies
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