Layers of the Heart…

Pericardial & Myocardial Disease

Ashlea WilmottPGY-1 FRCPC Emergency Medicine

Pericarditis Pericardial Effusion

Tamponade

WBC Trop ESR/CRPCK, CK-MB

LytesBUNCreatUrine and Serum tox

Stage

Time Frame EKG Findings

1 First hours-days

- Diffuse ST elevation (concave up)- Reciprocal ST depression in aVR and V1- Elevated PR segment in aVR and depression of PR elsewhere

(highly specific)

2 Variable - Normalization of ST and PR segments- T wave flattening

3 Variable - Diffuse T wave inversions - May not be seen in some patients

4 Weeks -months - Normalization- May have persistent T wave inversions

EKG FindingsPericarditis MI

ST segment elevation

- Begins at the J point- Rarely >5mm- Retains concavity

- Typical pattern is convex- Can exceed 5mm in height

Distribution - Generalized - Vessel distribution

Sequence - ST and T wave findings are NOT simultaneous

- Simultaneous

Normalization - Generally a longer process

Morphology - Each lead has its own characterization

- Vessel distribution of ST evolution

PR depression - Common - Rare

Pathologic Q wave

- Rare - Common

Arrhythmia - Rare - Common

EKG FindingsPericarditis Benign Early Repolarization

ST segment elevation

- Begins at the J point- Rarely >5mm- Retains concavity

- Begins at the J point- Maintains normal configuration

Distribution - Generalized - Most common V3-V6

PR depression - Common - Uncommon

Evolution of change

- Very Common - Uncommon

ST elevation to T wave amplitude ratio in V6

- >0.24 - <0.24

Benign Early Repolarization

+ LR 5.4

Causes of pericaditis

IdiopathicEverything Else

Causes of Pericarditis

P Post MI (Dressler’s Syndrome)

E Exocrine (Myexdema)

R Radiation induced

I Infectious

C Collagen Vascular Disease

A Amyloidosis, Anticoagulation, Aneurysm (dissection)

R Renal failure

D Drugs – The 5 P’s Penicillin, phenytoin, procainamide, pressure (hydralazine), pulmonary (INH)

I Idiopathic, Idiopathic Thrombocytopenic Purpura

T Trauma, Tumors (malignancy)

I Infective endocarditis with ring abscess

S Sarcoidosis

Infectious

PERICARDIAL

EFFUSION

TAMPONADE……

Signs and Symptoms of Cardiac Tamponade

Symptoms of Cardiac Tamponade

Symptom Sensitivity (%)

Dyspnea 87-89

Fever 25

Chest pain 20

Cough 7-10

Sign Frequency (%)

Elevated Neck Veins 100

Tachycardia 81-100

Systolic BP > 100 58-100

Pulsus Parodoxus >10mmHg 98

Pulsus Parodoxus > 20mm Hg 78

Pulsus Parodoxus >30mm Hg 49

Diminshed heart sounds 36-84

Hepatomegaly 58

Signs of Cardiac Tamponade

Signs of Cardiac Tamponade

Sign Sensitivity (%)

Pulsus paradoxus >10 mm HG 82 + LR 3.3

Tachycardia 77

Elevated JVP 76

Diminished heart sounds 28

Hypotension 26

Hypertension 33

Peripheral edema 21-28

Kussmaul 26

Sensitivity 89%- JAMA

EKG Findings of Cardiac Tamponade

Finding Sensitivity (%)

Low voltage EKG 42

Atrial arrhythmia 6

Electrical alternans 16-21

ST elevation 18-30

PR depression 18

Pericardiocentesis

Constrictive Pericarditis

Myocardial Disease

The Cardiomyopathies

Coxsackie BAdenovirus

Cardiac Enzymes