Acute Pericarditis

The patient is a 66-year-old man with hypertension and peripheral vascular disease, presented with one week history of intermittent chest pain, that worsens with inspiration and lying supine and is relieved with sitting up.

Figure 1. Admission EKG

See larger view of admission EKG

Figure 2. EKG after 4 hours.

See larger view of EKG after 4 hours

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ANSWER

Diagnosis: Acute Pericarditis.

EKG findings: ST segment elevation throughout the ECG, depression of P-R segment.

DISCUSSION

Acute Pericarditis: Inflammation or infiltration of pericardium.

Etiology:

• MI: occurs in first 24hrs or may occur from 1wk to several months after MI due to autoimmune reaction to the damaged heart muscles called Dressler’s syndrome.
• Infectious: viral, bacterial, tuberculous, fungal, amebic, toxoplasmosis.
• Collagen vascular disease: SLE, rheumatoid arthritis, and scleroderma.
• Drugs: procainamide, hydralazine, isoniazid.
• Uremia: common in chronic renal failure.
• Postpericardiostomy syndrome.
• Malignancy: primary or metastatic (pulmonary and breast cancer are common).
• Radiation: after mediastinal radiation.
• Trauma or post traumatic.

Clinical features:

• Symptoms: inspiratory chest pain, left side relieved by sitting up and leaning forward.
• Signs: classic sign is pericardial friction rub, which is scratchy, leathery sound heard both in systole and diastole.

Note: one of the comment for this video was helpful so i am posting it.

if you auscult a friction rub, it can be one of two things:

1. Pleural rub
2. Pericardial rub

If it's pericardial tell pt to hold breath and if sound continues it's pericardial bc those pleura will rub despite held breath. If it stops it's pleural.
If it's pleural it can be due to pneumonia. HOWEVER, a likely cause is pulmonary infarct 2ndary to PE! The dead lung inflames and rubs against the parietal pleura just like with pneumonia.

Diagnosis:

• Physical exam: pericardial friction rub.
• EKG: diffuse ST segment elevation without reciprocal ST segment depression, as seen in myocardial infarction. Depression of P-R segment is unique to pericarditis.
• Echocardiography: any form of pericardial inflammation can induce pericardial effusion and bleeding; therefore, an echocardiogram is recommended.
• Other Labs: CBC with diff, ESR, Viral titers, ANA, Rfactor, Renal function, cardiac enzymes.

Treatment:

• Treat the underlying cause.
• NSAIDs: aspirin, indomethacin and ibuprofen.
• Steroid therapy: patients should be given steroids if they are unresponsive to NSAIDs.

EKG Manifestations and Differential Diagnosis of Acute Pericarditis:

The EKG is a useful, simple tool that may aid in the diagnosis of acute pericarditis. Typical EKG findings include diffuse concave-upward ST segment elevation and, occasionally, PR-segment depression.

The EKG is useful in the diagnosis of acute pericarditis, with abnormalities found in approximately 90 percent of cases. Changes on EKG classically occur in four stages. In fact, all four stages are present in only 50 percent of patient or less.

1. Stage I: Typically occurs during the first few days of pericardial inflammation and is mainly characterized by Diffuse concave-upward ST segment elevation with concordance of T waves; ST-segment depression in aVR or V1; PR segment depression; low voltage; absence of reciprocal ST-segment changes.
2. Stage II: ST segment return to baseline; T wave flattening. This stage last from days to several weeks.
3. Stage III: T wave inversion. This stage begins at the end of the second or third week and last several weeks.
4. Stage IV: Gradual resolution of T-wave inversion and may last up to three months.

The most sensitive EKG changes in acute pericarditis is diffuse ST-segment elevation; a very specific change is depression of the PR segment in all leads except aVR and V1.

Differential Diagnosis of Acute Pericarditis by EKG:

• Myocardial infarction
• Early repolarization
• Myocarditis
• Pulmonary embolus
• Cerebrovascular accident
• Pneumothorax
• Hyperkalemia
• Subepicardial hemorrhage
• Ventricular aneurysm

Table 1. Comparison of EKG Changes Associated with Acute Pericarditis, Myocardial Infarction and Early Repolarization.

ECG Finding	Acute Pericarditis	Myocardial Infarction	Early Repolarization
ST-segment shape	Concave upward	Convex upward	Concave upward
Q waves	Absent	Present	Absent
Reciprocal ST-segment changes	Absent	Present	Absent
Location of ST-segment elevation	Limb and precordial leads	Area of involved artery	Precordial leads
ST/T ratio in lead V6	>0.25	N/A	0.25
Loss of R-wave voltage	Absent	Present	Absent
PR-segment depression	Present	Absent	Absent

This question was taken from: amc.edu