Transcript No Slide Title - Calgary Emergency Medicine

ECG rounds Nov 13/03
26 year old soccer player
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retrosternal chest pain.
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visiting from Egypt and did not speak
English. A friend gives a limited history.
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acute onset of chest pain earlier that
morning. 6/10
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The pain radiated into his neck and both
arms.
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associated nausea, vomiting,
presyncope, + diaphoresis.
Further history
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No history of similar sx, recent illnesses,
or trauma.
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Medical, surgical, and family history
unremarkable. He was taking no regular
no meds, no rec drugs
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smoker 10 pack years
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He denied risk factors for the HIV and
any history of exposure to tuberculosis.
Physical exam
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130/90 mm Hg in both arms, HR 106
RR 32, 37.5 sat 98% on RA
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moderate distress unable to lie flat on
the gurney.
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His lungs are clear, and auscultation of
the heart reveals only tachycardia. The
rest of the physical exam was normal.
pericarditis
Pericarditis
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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
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.
Pericarditis vs Infarction
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Common characteristics
– retrosternal or precordial with radiation to
the neck, back, left shoulder or arm
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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
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Pericarditis
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MI
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NO evolution of Q
waves
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Q waves may
evolve
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PR Segment
Depression
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T Wave inversion
after ST segments
return to baseline
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Not seen unless
Atrial infarct
T Waves invert as
ST segments
elevate
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Concave upward ST
Elevation
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Convex ST
Elevation
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ST Elevation in all
leads except aVR ±
V1
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ST Elevation
coincides to specific
coronary territory
Early repolarization
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most common in teenaged boys and
men in their 20s.
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the clinical syndrome of pain and
dyspnea is absent
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ECG does not, over time, evolve a
pattern of return of the ST segment to
baseline followed by T-wave inversion
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prior ECG may be helpful
Lead V6
Pericarditis
ST
concave
MI
Early repolarization
convex concave
ST:T in V6 >0.25
N/A
Reciprocal absent
changes
present absent
ST elev
location
Q waves
limb and
precordial
absent
present
PR
depression
<0.25
area of precordial leads
artery
present absent
absent
absent
ECG differential
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ECG
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AMI
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Early Repolarization
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Myocarditis
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Hyperkalemia
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Ventricular
Aneurysm
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Normal Variant
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CVA
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Pulmonary Embolus
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Pneumothorax
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Pneumopericardium
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Subepicardial
hemorrhage
Causes of pericarditis
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Idiopathic (75-80%)
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Viral, bacterial, TB,
fungal, rickettsia,
parasitic, endocarditis
SLE, RA, vasculitis,
scleroderma
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Wegener’s, PAN,
sarcoid, Crohn’s/UC,
Behcet’s
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Drug Induced:
Procainamide, INH,
hydralazine
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Hypothyroidism
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Renal Failure/Uremia
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Chylopericardium
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Post Radiation
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Neoplastic
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Post MI (us. large
infarct)
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Infarction pericarditis
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Trauma
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Dissecting Aneurysm
Common causes
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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, varicellazoster, influenza, Epstein-Barr, HIV,
adenovirus, echovirus
Common causes
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Inpatient setting
T = Trauma, TUMOR
U = Uremia
M = Myocardial infarction (acute, post)
Medications (hydralazine,
procainamide)
O = Other infections (Staph, Strep
pneumo, Hemophilus,
meningococcus, TB, fungal)
R = Rheumatoid, autoimmune disorder,
Radiation
Management
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The goals of therapy are relief of pain and
resolution of inflammation and effusion
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Treat underlying cause
In most patients, therapy should be
initiated with aspirin or an NSAID
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Follow-up within one week is appropriate
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Consider follow up ECG at 4 weeks but...
Back to the first case
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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.
References
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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.hypertensionconsult.com/Secure/textbookarticles/Textbook/58_ECG2.htm
Harrison’s Online
Medslides.com