Acute Pericarditis

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The diagnosis is made by meeting 2 of 4 criteria:

  1. Typical symptoms (pleuritic, sharp chest pain relieved when leaning forward)
  2. New pericardial effusion
  3. Presence of friction rub
  4. Typical ECG findings

Differentiating pericarditis from STEMI can be challenging, but features that suggest pericarditis over STEMI include any of the following: diffuse concave up ST elevations without reciprocal changes, PR depression, PR elevation in aVR, ST-elevation in lead II greater than lead III, and Spodick’s sign – down-sloping of the TP segment. It is important to note that the test characteristics of any single electrocardiographic feature is insufficient to rule in/out pericarditis, and that the feature with the highest odds ratio for predicting STEMI is reciprocal ST-depressions.

Examples

ECG Showing Acute Pericarditis

Acute Pericarditis

This patient developed diffuse ST-segment elevations during an inpatient admission and was discovered to have a new pericardial effusion and symptoms consistent with pericarditis. Note the diffuse nature of the ST-segment elevations without reciprocal changes, slight PR-segment depressions (best seen in the limb leads), and down-sloping T-P segment (best seen in the precordial leads, so-called Spodick's sign). Left heart catheterization revealed non-obstructive coronary artery disease and the patient was diagnosed with acute pericarditis. Months later, the ST-segments had normalized.

Acute Pericarditis

Note the diffuse concave ST-segment elevations without reciprocal ST-segment depressions. This patient was ultimately diagnosed with acute pericarditis.
ECG Showing Acute Pericarditis

Acute Pericarditis

Diffuse, concave up ST-segment elevation without reciprocal changes in a young patient diagnosed with acute pericarditis.
ECG Showing Acute Pericarditis

Acute Pericarditis

Diffuse, concave up ST-segment elevation without reciprocal changes in a cancer patient with a new pericardial effusion. Note the PR depressions and PR elevation in aVR.

References

  1. Wagner GS, Strauss DG. Marriott’s Practical Electrocardiography. 12th ed. Lippincott Williams & Wilkins; 2014.
  2. LeWinter MM. Acute Pericarditis. New England Journal of Medicine. 2017;371(25):349-359.
  3. Witting MD, Hu KM, Westreich AA, Tewelde S, Farzad A, Mattu A. Evaluation of Spodick’s Sign and Other Electrocardiographic Findings as Indicators of STEMI and Pericarditis. The Journal of Emergency Medicine. Published online March 2020.