A 22-year-old male athlete presents for pre-participation sports clearance. His ECG shows J-point elevation >0.1 mV, J-wave notching at the QRS-ST junction, and concave-up ST elevation in the lateral leads. The pattern marked **D** in the diagram is noted. Which of the following is the most appropriate next step in management?

Explanation

## Why Reassurance and clearance for athletic participation without restrictions is right Early repolarization (ER) is a benign ECG variant in most cases, particularly when it presents in young, athletic, healthy individuals with J-wave in lateral leads and upsloping ST elevation—exactly the pattern marked **D** in the diagram. According to Harrison 21e Ch 246, most asymptomatic patients with this low-risk ER pattern can be reassured and do not require activity restriction. The key clinical pearl is that recognition of the benign variant prevents unnecessary intervention and anxiety in healthy young athletes. ## Why each distractor is wrong - **Immediate coronary angiography to exclude acute coronary syndrome**: While ER must be distinguished from STEMI, the clinical context (young, asymptomatic athlete) and ECG features (concave-up ST elevation in lateral leads, no reciprocal changes, no evolving Q waves) are classic for benign ER, not acute coronary syndrome. STEMI shows convex-up ST elevation with reciprocal changes and regional distribution. - **Implantable cardioverter-defibrillator (ICD) placement for primary prevention**: ICD is reserved for high-risk ER patterns (J-wave in inferior leads with horizontal/descending ST segment and amplitude >0.2 mV) or survivors of sudden cardiac arrest with concomitant high-risk ER. This asymptomatic patient with lateral low-risk ER does not meet criteria for primary prevention ICD. - **Genetic testing for Brugada syndrome and long QT syndrome in all asymptomatic cases**: Genetic testing is indicated only in symptomatic patients (syncope, family history of sudden cardiac death <45 years) or those with high-risk ER features. Routine genetic screening in all asymptomatic ER cases is not standard practice and would lead to unnecessary testing and potential overdiagnosis. **High-Yield:** Most early repolarization in young, athletic individuals is benign (lateral J-wave + upsloping ST); distinguish from high-risk patterns (inferior J-wave + horizontal ST + amplitude >0.2 mV) which carry SCD risk. [cite: Harrison 21e Ch 246; Haïssaguerre et al. 2008 on high-risk ER patterns]