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Should We Still Use Electrocardiography to Diagnose 1-MINUTE CONSULT BRIEF ANSWERS TO SPECIFIC CLINICAL Q: Should we still use electrocardiography QUESTIONS to diagnose pericardial disease? M. CHADI ALRAIES, MD, FACP Department of Hospital Medicine, Medicine Institute, Cleveland Clinic Acute pericarditis is the most common peri- cardial syndrome and occurs in all age groups. ALLAN L. KLEIN, MD, FRCP(C), FACC, FAHA, FASE* Once diagnosed, it can easily be treated with anti- Department of Cardiovascular Imaging, Cardiovascular Institute, Cleveland Clinic inflammatory drugs. However, recurrent pericar- ditis, reported in 30% of patients experiencing yes. acute pericarditis has a unique a first attack of pericarditis, can be difficult to A: clinical presentation, physical find- manage, can have a significant impact on the ings, and electrocardiographic (ECG) chang- patient’s health, and can be life-threatening.2 es. ECG is always ordered to look for ischemic changes in patients with chest pain. Acute ■ CHANGES OF ACUTE PERICARDITIS pericarditis develops in stages, which makes it DEVELOP IN STAGES easy to differentiate from early repolarization and, more significantly, myocardial infarction. Pericarditis can be diagnosed on the basis of The ECG changes, along with the clinical pre- ECG changes, clinical signs and symptoms, sentation and physical findings, can make the and laboratory and imaging findings.3 ECG diagnosis of pericarditis. criteria of acute pericarditis have been pub- Acute In atypical and complicated cases, ad- lished.4,5 pericarditis vanced imaging studies (ie, echocardiography The characteristic chest pain in acute peri- and cardiac magnetic resonance imaging) carditis is usually sudden in onset and sharp and classically have been used to confirm the diagnosis and occurs over the anterior chest wall. The pain is causes to follow the course of the disease. However, exacerbated by inspiration and decreases when widespread ECG remains a useful, cost-effective test. the patient sits up and leans forward.4 ECG classically shows a widespread sad- upward concave ■ PERICARDIAL DISEASE IS DIVERSE dle-shaped (upward concave) ST-segment ST-segment elevation in the precordial and limb leads, re- The pericardium is a thin layer that covers the flecting subepicardial inflammation. PR-seg- elevation heart and separates it from other structures in ment depression (with PR-segment elevation the mediastinum. in lead aVR) can accompany or precede the Pericardial syndromes include acute, recur- ST changes and is known as the “discordant rent, constrictive, and effusive-constrictive peri- ST-PR segment sign” (FIGURES 1 AND 2). These carditis, as well as pericardial effusion with or changes are seen in 60% of patients. without tamponade. Causes include viral or bac- The ECG changes develop in stages, mak- terial infection, postpericardiotomy syndrome ing them easy to differentiate from early repo- (Dressler syndrome), postmyocardial infarction, larization and, more significantly, from myocar- primary and metastatic tumors, trauma, uremia, dial infarction. Four stages are apparent1,4,6–9: radiation, and autoimmune disease, but pericar- • Stage I occurs in a few hours to days, with dial syndromes can also be idiopathic.1 diffuse, up-sloping ST-segment elevation and upright T waves, the result of an alter- *Dr. Klein has disclosed that he has served on a steering committee for clinical trials for Bayer. ation in ventricular repolarization caused doi:10.3949/ccjm.80a.11144 by pericardial inflammation. Because of al- CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 80 • NUMBER 2 FEBRUARY 2013 97 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. ECG FOR PERICARDIAL DISEASE Postpericardiotomy syndrome (Dressler syndrome) FIGURE 1. Electrocardiogram of a 63-year-old man who presented with chest pain, fever, and a friction rub 4 weeks after cardiac bypass surgery. Note the diffuse up-sloping ST-segment elevations (blue arrows), best seen in II, III, and V2 to V6. Subtle PR-segment deviation (positive in aVR and negative in most other leads) is also present (green arrows). Postpericardiotomy syndrome (Dressler syndrome) is acute pericarditis that occurs 4 to 6 weeks after pericardiotomy. FIGURE 2. Electrocardiogram of a 19-year-old man who developed flu-like symptoms 2 weeks earlier. On the morning of this tracing he had fever, chest pain that worsened with deep breathing, and a pericardial friction rub. Note the diffuse up-sloping ST-segment elevations (blue arrows) and PR-segment depression in leads II and aVF (green arrows). Also note the low QRS amplitude, which suggests pericardial effusion. teration in repolarization of the atrium sec- Changes vary in duration. In some cases, ST ondary to inflammation, the PR segment is elevation returns to baseline within a few days elevated in aVR and depressed in the rest without T-wave inversions; in other cases, T- of the limb and chest leads. wave inversions can persist for weeks to months. • Stage II—the ST and PR segments nor- Sometimes the abnormalities resolve by the malize. time symptoms develop. • Stage III—widespread T-wave inversion. • Stage IV—normalization of the T waves. ■ ASSOCIATED CONDITIONS There is no pathologic Q-wave formation or loss of R-wave progression in acute pericarditis. Myocardial involvement The ECG changes of pericarditis vary widely In acute myocarditis, findings on ECG can from one patient to another, depending on the be normal unless the pericardium is involved. extent and severity of pericardial inflammation Changes that can be seen in myocarditis and and the timing of the patient’s presentation. that indicate a deeper involvement of inflam- 98 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 80 • NUMBER 2 FEBRUARY 2013 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. ALRAIES AND KLEIN mation include ST-segment abnormalities, ar- rhythmias (eg, premature ventricular or atrial contractions), pathologic Q waves, intraven- tricular conduction delay, and right or left bundle branch block.1,10–12 Elevated troponin and new focal or global left ventricular dysfunction on cardiac imag- ing indicates myocarditis, especially in a pa- tient with a normal coronary angiogram.10–13 Pericardial effusion: Tachycardia and low QRS voltage Pericardial effusion is often a complication of pericarditis, but it can also develop from other conditions, such as myxedema, uremia, malig- nancy, connective tissue disease, aortic dissec- tion, and postpericardiotomy syndrome, and it can also be iatrogenic. The most common ECG sign of pericardial effusion is tachycardia and low voltage of the QRS complexes. Low voltage is defined as a to- tal amplitude of the QRS complexes in each of the six limb leads less than or equal to 5 mm, FIGURE 3. Electrocardiogram of a 68-year-old man who devel- and less than or equal to 10 mm in V1 through oped shortness of breath 1 day after cardiac bypass surgery. V6. However, low voltage is not always present Cardiomegaly was found on plain chest radiography. This in the chest leads. tracing shows sinus tachycardia with electrical alternans: Mechanisms proposed to explain low QRS beat-to-beat alterations in the axis of the QRS complexes, voltage associated with pericardial effusion suggesting a large pericardial effusion with tamponade. include internal short-circuiting of the elec- trical currents by accumulated fluids within cavity, or anti-inflammatory drugs can resolve the pericardial sac, greater distance of the low QRS voltage within 1 week. heart from body surface electrodes, reduced cardiac size caused by effusion, and change in ■ DIFFERENTIAL DIAGNOSIS the generation and propagation of electrical OF ACUTE PERICARDITIS current in the myocardium.14,15 Acute myocardial infarction Cardiac tamponade: ECG changes in acute pericarditis differ from Tachycardia, electrical alternans, those in acute myocardial infarction in many low QRS voltage ways. Sinus tachycardia and electrical alternans are ST-segment elevation in pericarditis rarely specific but not sensitive signs of pericardial exceeds 5 mm, in contrast to acute myocar- 16,17 tamponade (FIGURE 3). Electrical alternans dial infarction, in which ST elevation at the is characterized by beat-to-beat alterations in J point has to be more than 2 mm and in two the axis of QRS complexes in the limb and anatomically contiguous leads.19 precordial leads as a result of the mechanical In pericarditis, the changes occur more swinging of the heart in a large pericardial ef- slowly and in stages, reflecting the evolving fusion.17 There is evidence to suggest that low inflammation of different areas of the peri- QRS voltage is more the result of the tampon- cardium. ade than the effusion.18 The ST segment is elevated diffusely in the Treating tamponade with pericardiocen- precordial and limb leads in pericarditis, indicat- tesis, surgical creation of a fistula (“window”) ing involvement of more than one coronary vas- between the pericardial space and the pleural cular territory, differentiating it from characteris- CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 80 • NUMBER 2 FEBRUARY 2013 99 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. ECG FOR PERICARDIAL DISEASE Acute pericarditis acute pericarditis, then PR elevation in aVR with PR depression in other leads may be seen. Finally, pathologic Q waves or high-grade heart block reflects acute myocardial infarction. Early repolarization: Elevation of the J point Early repolarization is sometimes seen in healthy P wave young people, especially in black men. Early repolarization is characterized by el- evation of the J point (ie, the junction between the end of the QRS complex and the beginning of the ST segment). Elevation of the J point causes elevation of the ST segment in the mid PR ST T Wave segment segment amplitude to lateral precordial leads (V3–V6) with an up- start onset 21 PR right T wave. segment Acute pericarditis tends to cause ST-segment end elevation in both the limb and precordial leads, whereas ST elevation in early repolarization FIGURE 4.
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