Kelly Patel

1. EKG OF THE MONTH
April 2017

2. 21 yo male with chest pain, dyspnea, and fevers x 2 weeks.
Diagnosis? Criteria?

3. HPI
• The patient is a 21y/o male with no significant PMH,
presenting to the EC with chest pain and dyspnea for 2
weeks.
• The patient states that his symptoms came on gradually,
accompanied by fatigue and intermittent fever. The chest
pain is tight in nature and improves when he lays on his
right side. Patient has never had these symptoms
before. Patient is unsure of sick contacts. The patient
denies headache, nausea, vomiting, diarrhea, numbness,
tingling, or any other symptoms.

4. Day 1

5. Day 1 – 20 min later

6. Day 3

7. Day 4

8. EC Labs
• WBC
• 16.0 (IG – 0.09)
• Troponin I
• First: 10.20
• Second: 9.55
• Third: 14.20

9. Pericarditis vs Myopericarditis
• Widespread concave ST elevation and PR depression
throughout most of the limb leads (I, II, III, aVL, aVF) and
precordial leads (V2-6).
• Reciprocal ST depression and PR elevation in lead aVR
(± V1).
• ST- and PR-segment changes are relative to the baseline
formed by the T-P segment. The degree of ST elevation is
typically modest (0.5 – 1mm).
• Sinus tachycardia is also common in acute pericarditis
due to pain and/or pericardial effusion.
• Myopericarditis: Pericarditis EKG changes + Elevated
cardiac enzymes

10. Pericarditis EKG Findings
• Widespread concave ST elevation and PR depression
• Compared to T-P baseline
• Reciprocal ST depression and PR elevation

11. Pericarditis Causes
• Infectious – mainly viral (e.g. coxsackie virus);
occasionally bacterial, fungal, TB.
• Immunological – SLE, rheumatic fever
• Uremia
• Post-myocardial infarction / Dressler’s syndrome
• Trauma
• Following cardiac surgery (post pericardiotomy syndrome)
• Paraneoplastic syndromes
• Drug-induced (e.g. isoniazid, cyclosporin)
• Post-radiotherapy

12. Pericarditis versus Benign Early Repolarization
Pericarditis can be difficult to differentiate from BER as both conditions
are associated with concave ST elevation.
One useful trick to distinguish between
these two entities is to look at the ST
segment / T wave ratio:
The vertical height of the ST segment
elevation (from the end of the PR segment
to the J point) is measured and compared
to the amplitude of the T wave in V6.
• A ratio of > 0.25 suggests pericarditis
• A ratio of < 0.25 suggests BER
Image Credit: http://www.rcemlearning.co.uk/

13. Clinical Course
• Patient was admitted for myopericarditis.
• Subsequent labs:
• WBC:
• Day 1: 16.0 (IG – 0.09)
• Day 2: 11.0
• Day 3: 8.8
• Troponin I
• Day 1: 10.20, 9.55, 14.20
• Day 3: 7.42
• TTE was normal.
• Cardiac MRI showed myopericarditis.
• “mid-myocardial delayed enhancement seen in the basal and mid inferolateral
wall, as well as a trivial but circumferential pericardial effusion”
• Patient was treated with indomethacin and colchicine.
• Low dose beta blocker added for cardioprotection.