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August 1, 2017 Circulation. 2017;136:e60–e122. DOI: 10.1161/CIR.0000000000000499 e84 4.3.5. Early Repolarization Pattern: Recommendations Early repolarization pattern is characterized by a distinct J point and ST elevation in the lateral or inferolateral leads. The pattern is more prevalent in young athletes, particularly African Americans, with 70% of the subjects being male.351 Early repolarization ECG pattern (>1 mm) in the inferior/lateral leads occurs in 1% to 13% of the general population and in 15% to 70% of idiopathic VF cases.352–354 Furthermore, it has been shown in population-based studies to be associated with increased risk of cardiac death.352,353,355–357 One study showed that the presence of a J wave increased the risk of VF from 3.4/100 000 to 11.0/100 000.353 However, given the low incidence of VF in the general population, the absolute risk in patients with early repolarization remains low. In patients with syncope, the clinical significance of the early repolarization pattern is unknown. Recommendations for Early Repolarization Pattern COR LOE Recommendations IIb C-EO ICD implantation may be considered in patients with early repolarization pattern and suspected arrhythmic syncope in the presence of a family history of early repolarization pattern with cardiac arrest. N/A ICD implantation may be considered in patients with early repolarization pattern and suspected cardiac syncope if they have a family history of unexplained SCD, VF, or polymorphic VT with documented early repolarization pattern in the affected family member.358,359 III: Harm B-NR EPS should not be performed in patients with early repolarization pattern and history of syncope in the absence of other indications.359 See Online Data Supplement 24. In a multicenter study including 81 patients with early repolarization syndrome and aborted SCD who underwent EPS, VF was inducible in only 22% of cases. The VF recurrence rate was similar in patients who were inducible and in those who were noninducible.359 Given the high prevalence of early repolarization, the possibility of inducing VF in healthy individuals, and the limited value of ventricular programmed stimulation in risk stratification, EPS is not recommended in patients with early repolarization and syncope in the absence of other cardiac indications.352,353,360 5 REFLEX CONDITIONS: RECOMMENDATIONS 5.1 Vasovagal Syncope: Recommendations V VS is the most common cause of syncope and a frequent reason for ED visits.66 The underlying pathophysiology of V VS results from a reflex causing hypotension and bradycardia, triggered by prolonged standing or exposure to emotional stress, pain, or medical procedures.361–365 An episode of V VS is typically associated with a prodrome of diaphoresis, warmth, and pallor, with fatigue after the event. Given the benign nature of V VS and its frequent remissions, medical treatment is usually not required unless conservative measures are unsatisfactory. In some patients, effective treatment is needed, as syncopal events may result in injury and an impaired quality of life (QoL).366–368 Despite the need and substantial efforts by investigators, there are limited evidence-based therapeutic options.369 Preliminary data from cardiac ganglia plexi ablation in treating selected patients with V VS are encouraging but still insufficient to make recommendations at this time.370–372 See Figure 4 for the algorithm for treatment of V VS. Recommendations for V VS COR LOE Recommendations I C-EO Patient education on the diagnosis and prognosis of V VS is recommended. See Online Data Supplements 25 and 26. In all patients with the common faint or V VS, an explanation of the diagnosis, education targeting awareness of and possible avoidance of triggers (eg, prolonged standing, warm environments, coping with dental and medical settings), and reassurance about the benign nature of the condition should be provided. IIa B-R Physical counter-pressure maneuvers can be useful in patients with V VS who have a sufficiently long prodromal period.373–375 See Online Data Supplements 25 and 26. Patients with a syncope prodrome should be instructed to assume a supine position to prevent a faint and minimize possible injury. In patients with a sufficiently long prodrome, physical counter-maneuvers (eg, leg crossing, limb and/or abdominal contraction, squatting) are a core management strategy. In a randomized, parallel, open-label trial, leg crossing with conventional therapy (ie, fluid, salt intake, counseling, and avoidance) was superior to conventional therapy in preventing syncope recurrence.375 IIb C-LD LCSD may be reasonable in patients with CPVT, syncope, and symptomatic VA despite optimal medical therapy.348–350 See Online Data Supplements 22 and 23. When syncope occurs despite optimal medical therapy, LCSD may be a reasonable therapy.348–350 In a worldwide cohort study, the percentage of patients with major cardiac events despite optimal medical therapy was reduced 68% after LCSD.349 Recommendations for CPVT (Continued) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026