ECG rounds Nov 13/03

26 year old soccer player retrosternal chest pain. visiting from Egypt and did not speak English. A

friend gives a limited history. acute onset of chest pain earlier that morning.

6/10 The pain radiated into his neck and both arms. associated nausea, vomiting, presyncope, +

diaphoresis.

Further history

No history of similar sx, recent illnesses, or trauma.

Medical, surgical, and family history unremarkable. He was taking no regular no meds, no rec drugs

smoker 10 pack years He denied risk factors for the HIV and any

history of exposure to tuberculosis.

Physical exam

130/90 mm Hg in both arms, HR 106 RR 32, 37.5 sat 98% on RA

moderate distress unable to lie flat on the gurney.

His lungs are clear, and auscultation of the heart reveals only tachycardia. The rest of the physical exam was normal.

pericarditis

Pericarditis ECG abnormalities found in 90% of cases The most sensitive change is diffuse ST elevation

which reflects abnormal repolarization due to inflammation

The most specific change is PR depression (not sensitive) occurs in all leads except aVR and V1- reflects subepicardial atrial injury

May see notching of the end of the QRS If effusion: low voltage QRS, electrical alternans Usually no arrhthmia if just pericarditis

Four StagesFirst hours to days:

– diffuse upsloping ST elevation with reciprocal ST depression (aVR, V1)

– PR depression in the inferolateral leads (II, III, AVF, V5-6)– PR elevation in aVR

2. Normalization of the ST and PR segments 1- 2 weeks3. Diffuse T wave inversions, usually after ST segments

become isoelectric. (this phase is not seen in some patients.) End of second or third week

4. ECG may become normal or the T wave inversions may persist indefinitely ("chronic" pericarditis). May last up to three months.

Pericarditis vs Infarction Common characteristics

– retrosternal or precordial with radiation to the neck, back, left shoulder or arm

Special characteristics (pericarditis)– more likely to be sharp and pleuritic with coughing, inspiration, swallowing– worse by lying supine, relieved by sitting and leaning forward– may have low grade fever– triphasic friction rub (systolic, early diastolic and presystolic)

LLSB sitting frwd

Pericarditis NO evolution of Q waves PR Segment Depression T Wave inversion after ST

segments return to baseline

Concave upward ST Elevation

ST Elevation in all leads except aVR ± V1

MI Q waves may evolve Not seen unless Atrial

infarct T Waves invert as ST

segments elevate Convex ST Elevation ST Elevation coincides to

specific coronary territory

Early repolarization most common in teenaged boys and men

in their 20s. the clinical syndrome of pain and dyspnea

is absent ECG does not, over time, evolve a pattern

of return of the ST segment to baseline followed by T-wave inversion

prior ECG may be helpful

Lead V6

Pericarditis MI Early repolarizationST concave convex concave

ST:T in V6 >0.25 N/A <0.25

Reciprocalchanges

absent present absent

ST elevlocation

limb andprecordial

area ofartery

precordial leads

Q waves absent present absent

PRdepression

present absent absent

ECG differential

CVA Pulmonary Embolus Pneumothorax Pneumopericardium Subepicardial

hemorrhage

ECG AMI Early Repolarization Myocarditis Hyperkalemia Ventricular Aneurysm Normal Variant

Causes of pericarditis Idiopathic (75-80%) Viral, bacterial, TB, fungal,

rickettsia, parasitic, endocarditis

Post Radiation Neoplastic Post MI (us. large infarct) Infarction pericarditis Trauma Dissecting Aneurysm

SLE, RA, vasculitis, scleroderma

Wegener’s, PAN, sarcoid, Crohn’s/UC, Behcet’s

Drug Induced: Procainamide, INH, hydralazine

Hypothyroidism Renal Failure/Uremia Chylopericardium

Common causes

Outpatient setting– usually idiopathic– probably due to viral infections– Coxsackie A and B (highly cardiotropic)

are the most common viral cause of pericarditis and myocarditis

– Others viruses: mumps, varicella-zoster, influenza, Epstein-Barr, HIV, adenovirus, echovirus

Common causes Inpatient setting

T = Trauma, TUMORU = UremiaM = Myocardial infarction (acute, post)

Medications (hydralazine, procainamide)O = Other infections (Staph, Strep pneumo, Hemophilus, meningococcus, TB, fungal)R = Rheumatoid, autoimmune disorder,

Radiation

Management

The goals of therapy are relief of pain and resolution of inflammation and effusion

Treat underlying cause In most patients, therapy should be

initiated with aspirin or an NSAID Follow-up within one week is appropriate Consider follow up ECG at 4 weeks but...

Back to the first case

The patient was transferred to the cardiac care unit. He improved slowly on NSAIDs. Serial cardiac enzymes proved to be unremarkable. An echocardiogram was performed and revealed no significant abnormalities.

References Alan E. Lindsay ECG Learning Center in Cyberspace

http://medlib.med.utah.edu/kw/ecg/ American Academy of Family Physicians

http://www.aafp.org/afp/980215ap/marinell.html Best Practice of Medicine - cardiology http://merck.praxis.md/index.asp?

page=bpm_tabfig&article_id=BPM01CA09 Clinical Electrocardiography - A Simplified Approach 6th ed. Goldberger ECG library - Jenkins, D. Gerred, S. Electrocardiographic Diagnosis - Specific Clinical syndromes Brady, W.

http://www.hypertension-consult.com/Secure/textbookarticles/Textbook/58_ECG2.htm

Harrison’s Online Medslides.com