Acute Pericarditis/
ECG conference
Jimmy Klemis, MD
Jan 8, 2002
Pericardium
 Visceral / serous
– Direct contact with epicardium (ST elev)
– single layer mesothelial cells
 Parietal / fibrous
– mesothelial and fibrous layer
Pericardial Anatomy
Visceral – transparent
Parietal – translucent
Transverse sinus – curved probe
 Infectious
Etiology – Acute Pericarditis
– Viral : Coxsackie, Echo, EBV, Influenza, HIV
– Bacterial: TB, staph, hemophillus, pneumococcal, salmonella
– Fungal/other: histo/blasto/coccidio, rickettsia
 Rheumatologic
– SLE, Sarcoid, RA, Dermatomyositis, Ankylosing Spondylitis,
Scleroderma, PAN
 Neoplastic
– Primary: angiosarcoma, mesothelioma
– Metastatic: breast, lung, lymphoma, melanoma, leukemia
 Immunologic
– Celiac sprue, Inflammatory Bowel Disease
 Drug
– Hydralizine, Procainamide
 Other
– MI, Dressler’s, Post Pericardiotomy, Chest Trauma, Aortic dissection
– Uremic, Post Radiation
– IDIOPATHIC
Acute Pericarditis – Clinical
 History
– preceding viral illness, etc
 Symptoms
– Chest pain
 Signs
– Friction Rub
 ECG
– early: PR / ST changes
– late: isoelectric ST/ T inv
History
 Often preceding viral illness 1-2wk prior
 Chest Pain
– Sudden, sharp,pleuritic, constant
– worse supine/ L lat decub, relief sitting up
– radiation: back, trapezius ridge
– symptoms usually resolve by 2 weeks, ECG
abnormalities may persist for months
Auscultory – Rub(s)
 Endopericardial (classic)
–
–
–
“triphasic”: atrial sys, ventricular sys, early diastole
may only hear 2 phase (afib or tachycardia) or 1
loudest LSB, raised extremities/increased venous return
 Pleuropericardial
–
–
“exopericardial”, extension into adjacent structures
marked resp variation, musical quality
 Conus
–
–
dilation of pulm conus in hyperactive heart
PE, thyroid storm, acute beriberi
 Pneumohydropericardium
– air/gas overlying pcard fluid
– metallic tinkle (small amt) ; churning/splashing “mill-wheel sound” (lg)
ECG
 PR depression
 ST elevation
– concave up, ST/T V6 >.25, no reciprocal
 DDx:
–
–
–
–
–
Acute MI
Early Repolarization
Myocarditis
Aneurysm
other: Brugada, BBB
ECG
Acute Pericarditis - Stages
 Stage I
– first few days  2 weeks
– ST elev, PR depression
– up to 50% of pt with sxs/rub do NOT have/evolve stage I1
 Stage II
– last days  weeks
– ST returns to baseline, flat T
 Stage III
– after 2-3 weeks, lasts several weeks
– T wave inversion
 Stage IV
– lasts up to several months
– gradual resolution of T wave changes
1
Spodick DH, Pericardial Disease. Braunwauld 6th
Acute PCARD – Stage I, II
60 y/o man with acute PCARD on presentation and after 1 mo resolution of sxs,
* Marriott’s Practical ECG 10th ed, p 208
Acute PCARD – Stage III
19 y/o Female after 1 wk in hospital with Acute Pericarditis
DDx: PCARD vs Repol
Sex
Acute
Pericarditis
Either
Early
Repolarization
Usually Male
Age
Any
Usually < 40
PR segment dev Common
Uncommon
T waves
tall, peaked
nl, blunt
J-ST / T ampl V6 > 25%
<25%
Tallest
precordial R
Usually V4
Usually V5
DDx: PCARD vs MI
Pericarditis
Angina, ischemia
J-ST
Diffuse concave
Localized, convex, w/
elevation w/o reciprocal reciprocal changes in
changes
infarct
PR depression
Frequent
Almost never
Q waves
Not usual, unless with
infarct
Common with q wave
infarct
T waves
Inverted after J returns
to baseline
Inverted while ST still
elevated
Arrhythmia
Rare
Frequent
Conduction
disturbances
Rare
frequent
Cardiac Isoenzymes - ? helpful
 2 year study, ER based1
– 14 pt with 2/3 findings (CP typical for PCARD,
rub, and ECG changes c/w PCARD)
– 71% had elevated TropI (pk 21) with negative
CAD workup
 Not reliable to differentiate MI vs PCARD
1Brandt
RR, et al. Am J Card 2001, June 1
Treatment
 NSAIDS/ASA
– ASA 650 q3-4hr
– Ibuprofen 300-600 q 6-8 hrs x 1-4days
 Avoid Indocin, reduces CBF
 Steroids
– if no response after 48hr NSAID
– use concurrent NSAID
 Colchicine
– .6 q12 chronic +/- NSAID
– useful in recurrent pericarditis
– symptom free period 3.1 +/- 3mos vs 43 +/- 35mos (p<.00001)
in largest multicenter trial to date1
– Anecdotal evidence of benefit in Acute PCARD, effusion
1Adler
Y, et al. Circulation, 1998 June 2
Complications
 Pericardial Effusion/Tamponade
 Constrictive Pericarditis
– can be “transient” – 10% may have transient
sxs within 1st month, resolves by 3 months
 Recurrent Pericarditis (20-25%)
– Rx – NSAIDS/Colchicine +/- steroids
Gross Pathology
“Bread & Butter” appearance
Fibrinous stranding
Acute PCARD – Stage I
ECG Quiz
Acute Pericarditis, Stage I
Acute Ant MI
ECG quiz 2
Early Repolarization
ECG quiz 3
Early Repolarization
ECG quiz 4
ECG Quiz 5
Pericardial dz, diffuse ST elev
ECG Quiz 6
Acute antseptal MI
ECG Quiz 6a
ECG Quiz 7
Early Repolarization
ECG quiz 8
Incomplete RBBB