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ECG --    September 2019

 

Case presentation

Paramedics respond to a 43-year-old male with no significant past medical history presenting with chest pain.  The patient complains of 3 hours of sharp pain to the mid-chest that does not radiate.  His pain is worse with deep breaths and when he lies down. 

Vital signs are blood pressure 122/84, HR 100, RR 16, O2 saturation 100%.  His lungs are clear to auscultation and his chest pain is not reproducible. 

1.

What is your interpretation of this ECG?

Rate:                                                ~110 bpm                             

Rhythm:                                          Sinus Rhythm – there are p waves before each QRS

ST Segment Elevation >1mm

In 2 or more contiguous

Leads?:                                           Yes, ST segments are elevated in leads I, II, III, aVF, V4-V6

Reciprocal Changes:                      No                  

Other Abnormalities:                     There is PR-segment depression in leads I, II, III, aVF, V4-V6

Learn more about this ECG pattern

This ECG pattern is consistent with acute pericarditis.  Pericarditis is inflammation of the pericardium (the sac that contains the heart).  Most cases are related to viral infections, but other causes include systemic rheumatologic disease (rheumatoid arthritis, vasculitis, etc.) malignancy, or medication use.  Oftentimes, the underlying cause is unknown. 

Patients with pericarditis classically present with sharp central chest pain that worsens with lying supine and improves if they sit up and/or lean forward.  ECG findings consistent with pericarditis include diffuse concave-upward ST segment elevation and PR segment depression.  On physical examination, one can occasionally ausculate a friction rub along the inferior portion of the left sternal border.  

The pericardium consists of two layers.  The outer layer is fibrous and the inner layer is a serosal layer that overlies the surface of the epicardium.  In between the two layers is a potential space.  When the pericardium is inflamed, abnormal repolarization occurs which leads to diffuse ST segment elevation.  Other findings include ST segment depression in aVR and V1.  PR segment depression is very specific to acute pericarditis.  ST-segment elevation is typically diffuse on the ECG in pericarditis and there are no reciprocal changes as oftentimes seen with ST-segment elevation related to myocardial infarction2

2.

How would you manage this patient in the field?

It may be difficult to distinguish pericarditis from ischemic cardiac chest pain in the field, but the ECG in this case is classic for pericarditis.  The provider impression for pericarditis is Cardiac Chest Pain and the patient should be managed in accordance with TP-1211, Cardiac Chest Pain.  The ECG findings are not consistent with STEMI given diffuse ST segment elevation, without reciprocal changes of ST depression.  The patient should be transported to the MAR for evaluation and treatment. 

Most cases of pericarditis improve with outpatient treatment including non-steroidal anti-inflammatory medications.  Patients with high fevers, immunosuppression, large pericardial effusions, cardiac tamponade, involvement of the myocardium, or failed non-steroidal anti-inflammatory treatment may require inpatient hospital treatment2

References

  1.  https://litfl.com/pericarditis-ecg-library/
  2. Acute Pericarditis:  Diagnosis and Management.  https://www.aafp.org/afp/2014/0401/p553.html.  Accessed 9/3/19.

 

Author: Dr. Denise Whitfield, MD, MBA