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Challenging ST segments in an adolescent with chest pain

A 16 years old black male presents to the pediatric emergency department with chest pain. He frequently plays soccer and goes to the gym. No complaints on exercise, no history of syncope, no family history of cardiovascular disease. Chest pain on the left hemithorax, radiating to the left arm. Onset 2 hours ago. No history of injury. Regular breathing, no nausea or vomiting.

The ECG recorded at the emergency ward showed the following:

Due to ST elevations in the inferior leads and chest leads he was admitted and presented to the on-call pediatric cardiologist.

Echocardiography was normal. Lab values showed normative values for myocardial enzymes, slightly elevated creatine kinase (CK), and no signs of infection/inflammation.

Physical exam revealed localized chest pain triggered by physical pressure on the 4th & 5th rib. Thus, no cardiac cath was ordered. Symptoms resolved by pain medication. Patient was discharged.

Reviewing the ECG, this is typical "benign early repolarization" (BER) pattern in a young athletic male. BER is considered to appear in up to 80% of african-american adolescent males, and is considered a benign normal variant not requiring therapy.

Criteria for BER include the following:

- Widespread concave ST elevation, most prominent in V2-V5

- Notching or slurring at the J point

- Prominent, slightly asymmetrical T waves, concordant with the QRS complex

- ST elevation/T wave height ratio in V6 < 0.25

- No reciprocal ST depression to suggest Occlusion Myocardial Infarction (OMI)

- "Fish hook" sign usually present in V4 (notching of the J point)

More information on BER and several ECG examples can be found at

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