This 68-year-old woman is brought to the Emergency Department because of severe pain for the past 2-3 hours, initially on the back of her neck and left shoulder, later moving to her anterior chest, worse on taking deep breaths and on sitting up:

• Sinus rhythm, 69/min
• ST elevation compatible with early repolarization (a normal variant). In view of the clinical presentation that is strongly suggestive of pericarditis, follow-up ECGs should be obtained.

On the basis of her symptoms, it was felt that pericarditis was the most likely clinical diagnosis. As she was already on large doses of aspirin for chronic arthritis, the patient was started on colchicine, resulting in significant improvement of her chest pain. On the following day a pericardial friction rub was heard on the precordium, that increased during deep inspiration.
The following ECG was recorded:

• Sinus rhythm, 70/min
• Compared with the previous tracing, the ST elevation has increased in several leads and the ST/T voltage ratio no longer meets the criteria for early repolarization
• Acute pericarditis

Patients with pericarditis or myocardial infarction may present with ST elevation in their first ECG that meets the criteria for early repolarization (a normal variant). As such, correlation with the clinical picture is particularly important in the interpretation of ECG tracings with ST elevation suggestive of early repolarization.