ECG rounds Nov 13/03

1. ECG rounds Nov 13/03

2. 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.

3. 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.

4. 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.

5. pericarditis

6. 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

7. Four Stages First 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 weeks 3. 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.

9. 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

10. 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

11. 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

13. Lead V6

16. CVA Pulmonary Embolus Pneumothorax Pneumopericardium Subepicardial hemorrhage ECG AMI Early Repolarization Myocarditis Hyperkalemia Ventricular Aneurysm Normal Variant ECG differential

17. 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 Causes of pericarditis

18. 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

19. Common causes • Inpatient settingT = 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

20. 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...

22. 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.

23. 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