ECG: Pericarditis

1. ECG OF THE WEEKECG OF THE WEEK
PROF.DR.K.H NOORUL AMEEN UNITPROF.DR.K.H NOORUL AMEEN UNIT
DR.M.JAGADEESANDR.M.JAGADEESAN
I YR PGI YR PG

2. A 58 year old male came with c/o A 58 year old male came with c/o
breathlessness,chest pain.k/c DM, SHT breathlessness,chest pain.k/c DM, SHT
,CKD,CKD
o/e pedal edema o/e pedal edema

3. Ecg takenEcg taken

4. findingsfindings
NSRNSR
HR 100/minHR 100/min
P wave morphology-NP wave morphology-N
QRS axisQRS axis
QRS-NQRS-N
ST segment –concave upwards in ST segment –concave upwards in
L1,LII,avL,avF,V4-V6 ;depressed in L1,LII,avL,avF,V4-V6 ;depressed in
avR&V1.avR&V1.

5. PERICARDITISPERICARDITIS
–Pericarditis is a disorder caused by Pericarditis is a disorder caused by
inflammation of the pericardium , the serous inflammation of the pericardium , the serous
membrane enclosing the heart and the roots membrane enclosing the heart and the roots
of the great blood vessels.of the great blood vessels.
–Fibrinous, aseptic inflammation Fibrinous, aseptic inflammation
(predominantly lymphocytic) is the hallmark of (predominantly lymphocytic) is the hallmark of
uremic pericarditis.uremic pericarditis.

6. Evolution of pericarditisEvolution of pericarditis
Acute phaseAcute phase
Subacute or evolving phaseSubacute or evolving phase
Chronic phaseChronic phase

7. Basic electrocardiographic effectsBasic electrocardiographic effects
Acute epicardial injury is reflected by ST Acute epicardial injury is reflected by ST
segment deviation towards the injured segment deviation towards the injured
surface.surface.
Epicardial ischemia is reflected by T wave Epicardial ischemia is reflected by T wave
deviation away from the ischemic regiondeviation away from the ischemic region
Electrical short circuiting effect results in Electrical short circuiting effect results in
dimished magnitude/electric alternansdimished magnitude/electric alternans

8. Acute pericarditisAcute pericarditis
 ECG changes include diffuse concave upward ST ECG changes include diffuse concave upward ST
elevation, except in leads aVR and V1 (usually elevation, except in leads aVR and V1 (usually
depressed). T waves are upright in the leads with ST depressed). T waves are upright in the leads with ST
elevation.elevation.
Upright T waves may be the earliest signUpright T waves may be the earliest sign
Sinus tachycardia is almost invariably associated.Sinus tachycardia is almost invariably associated.
The reciprocal ST segment changes or pathological Q The reciprocal ST segment changes or pathological Q
wqves of MI not seenwqves of MI not seen
The most sensitive ECG change characteristic of acute The most sensitive ECG change characteristic of acute
pericarditis is ST-segment elevation, which reflects the pericarditis is ST-segment elevation, which reflects the
abnormal repolarization that develops secondary to abnormal repolarization that develops secondary to
pericardial inflammation.2 Depression of the PR segment pericardial inflammation.2 Depression of the PR segment
is very specific of acute pericarditis and is attributed to is very specific of acute pericarditis and is attributed to
subepicardial atrial injury and occurs in all leads except subepicardial atrial injury and occurs in all leads except
aVR and V1. These leads may exhibit PR-segment aVR and V1. These leads may exhibit PR-segment
elevationelevation. .

10. Subacute or evolving phaseSubacute or evolving phase
ST segment changes tending to become ST segment changes tending to become
convex upward and then isoelectricconvex upward and then isoelectric
T wave also loses amplitude and becomes T wave also loses amplitude and becomes
isoelectricisoelectric

11. chronicchronic
It is characterised byIt is characterised by
Low to inverted T waves in most leadsLow to inverted T waves in most leads
Diminished amplitude of all the ecg Diminished amplitude of all the ecg
detectionsdetections
Potential elctrical alternans best seen in Potential elctrical alternans best seen in
midprecordial leadsmidprecordial leads

13. ChronicChronic

15. DD –ST elevationDD –ST elevation
MIMI
ACUTE PERICARDITISACUTE PERICARDITIS
LVHLVH
VENTRICULAR ANEURYSMVENTRICULAR ANEURYSM
ERSERS
HYPOTHERMIAHYPOTHERMIA

16. Single electrocardiographic complexes comparing (left) Single electrocardiographic complexes comparing (left)
acute pericarditis, (center) early repolarization and (right) acute pericarditis, (center) early repolarization and (right)
injury pattern of acute myocardial infarction. The degree of injury pattern of acute myocardial infarction. The degree of
ST-segment elevation is greater in the pericarditis complex ST-segment elevation is greater in the pericarditis complex
than in the early repolarization complex. Important findings than in the early repolarization complex. Important findings
of acute infarction include the presence of Q waves and a of acute infarction include the presence of Q waves and a
more convex upward ST segment, both of which are more convex upward ST segment, both of which are
present in the right complex. present in the right complex.

17. ECG finding Acute pericarditis
Myocardial
infarction
Early
repolarization
ST-segment shape Concave upward Convex upward Concave upward
Q waves Absent Present Absent
Reciprocal ST-segment changes Absent Present Absent
Location of ST-segment elevation Limb and precordial
leads
Area of involved
artery
Precordial leads
ST/T ratio in lead V6* >0.25 N/A <0.25
Loss of R-wave voltage Absent Present Absent
PR-segment depression Present Absent Absent

19. CAUSESCAUSES
ACUTE RHEUMATIC FEVERACUTE RHEUMATIC FEVER
VIRALVIRAL
UREMIA RELATEDUREMIA RELATED
Late start of, or inadequate hemodialysis Late start of, or inadequate hemodialysis
Retained uremic toxins Retained uremic toxins
Loss of residual renal function Loss of residual renal function
DRESSLERDRESSLER
TBTB
MYXOEDEMAMYXOEDEMA
MALIGNANCYMALIGNANCY
Side effectSide effect of some of some medicationsmedications, e.g. , e.g. isoniazidisoniazid, ,
cyclosporinecyclosporine, , hydralazinehydralazine, , warfarinwarfarin, and , and heparinheparin

21. AcuteAcute