Case A15. Pericarditis. St Emlyn’s ECG Library

History

The ECG was recorded from a 50 year old man with a two day history of retrosternal chest pain associated with a ‘flu like illness. The pain was aggravated by movement, coughing or taking deep breaths but relieved by sitting forwards. There was a pericardial rub well heard at the cardiac apex.

ECG

There is elevation of the ST segments in leads I, II, III, aVF and VI – V6. Lead aVR shows ST depression. There are no pathological Q waves and the pattern of R wave progression is normal. The PR interval is prolonged at .22 seconds; first degree AV block is present.

Comment

The ECG shows the typical appearances of acute pericarditis. The morphology of the ST segment in pericarditis is often described as different to that seen in acute ischaemia; the ST segments in pericarditis show the more ‘concave upwards’ appearance seen in this case as opposed to the ‘convex upwards’ appearance seen in early infarction. A more reliable sign however is the widespread distribution of the
changes in pericardids occuring in most ECG leads, compared to the changes of ischaemia which are usually localized to leads recording from one area of the ventricle. The changes in pericarditis are thought to be due to inflammation of the myocardium in the area adjacent to the inflamed pericardium; this is a widespread process involving all the areas of myocardium covered by pericardium. Acute ischaemia is a localized process and the ST changes are restricted to the leads that record from the area deprived of oxygenated blood. In this ECG the ST elevation is present in all leads except aVR and aVL. aVR is an intracavity lead and shows ST depression (a reciprocal change). Lead aVL is at right angles to the frontal plane axis and shows only a small QRS deflection and there is no significant ST segment deviation. Small rises in serum hsTroponin is common. Patients should have an ECHO performed to look for signs of pericardial effusion.

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