High-take off or ST elevation?

Clinical Relevance

High-take off (AKA benign early repolarisation; J-point elevation) is an ECG pattern most commonly seen in young, healthy patients < 50 years of age.

  • It produces widespread ST segment elevation that may mimic pericarditis or acute MI.
  • Up to 10-15% of ED patients presenting with chest pain will have high-take off on their ECG, making it a common diagnostic challenge for clinicians. It is generally thought to be a normal variant that is not indicative of underlying cardiac disease.
  • High-take off is less common in the over 50s, in whom ST elevation is more likely to represent myocardial ischaemia.
  • It is rare in the over 70s.

Avoid diagnosing High-take off in patients over the age of 50, especially those with risk factors for ischaemic heart disease.

Key ECG Features

There are some key features on an ECG that distinguish high-take off from an ST elevation MI. 

  • Usually follows an S wave
  • T wave maintains independent wave form
  • No reciprocal ST segment depression (except aVR) 
  • Widespread concave ST elevation, most prominent in V2-5
  • Notching or slurring at the J-point
  • The degree of ST elevation is modest in comparison with the T-wave amplitude
  • ST elevation is usually <2mm in the precordial leads and <0.5mm in the limb leads
  • ST changes are stable over time and don’t progress

High-take off example 

As you can seen on the ECG example below the ST elevation in the precordial leads is slurred upwards, and the elevation is widespread across the ECG. High-take off can also be confused with pericarditis for this reason. Generally the ST elevation is minimal and each lead has its own defined T waves. There is also no ST depression on the ECG. 

Key Learning Point

High-take off is a common presentation in the ED, and although more common in younger people, and often an incidental finding, from a nursing point of view, all elevation is to be considered acute ST elevation until proven otherwise. Always remember to look at and listen to your patient. An ECG only tells you part of the story in that very brief electronic capture. Your history taking and symptom management is what is key, always escalating appropriately. 

For further reading see https://litfl.com/benign-early-repolarisation-ecg-library/ 

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