subtle manifestations of deadly cardiac...

Subtle Manifestations of Subtle Manifestations of Deadly Cardiac DiseaseDeadly Cardiac Disease

Amal Mattu, MD, FACEPAmal Mattu, MD, FACEPProgram Director, Emergency Medicine ResidencyProgram Director, Emergency Medicine Residency

Professor Department of Emergency MedicineProfessor Department of Emergency MedicineProfessor, Department of Emergency MedicineProfessor, Department of Emergency MedicineUniversity of Maryland School of MedicineUniversity of Maryland School of Medicine

lectures.umem.org/ACEP2010lectures.umem.org/ACEP2010

Case 1Case 1Case 1Case 1

87 b87 b87 yo. man became nauseous, 87 yo. man became nauseous, diaphoretic, and pale while in churchdiaphoretic, and pale while in church●● No chest pain or dyspneaNo chest pain or dyspnea●● “Funny feeling under my chest”“Funny feeling under my chest”●● ECG interpreted as normal in EDECG interpreted as normal in ED●● Cardiologist reads “NSC from previous Cardiologist reads “NSC from previous

ECG” (4 years earlier)ECG” (4 years earlier)

Baseline ECGBaseline ECGBaseline ECGBaseline ECG


Patient’s nausea is treated with Patient’s nausea is treated with antiemeticsantiemeticsPallor resolves with IVFPallor resolves with IVFSL NTG has no effect on “funny feeling” SL NTG has no effect on “funny feeling” in chestin chestin chestin chest●● No further interventions/treatmentNo further interventions/treatment

Plans are made for admission forPlans are made for admission forPlans are made for admission for Plans are made for admission for “dehydration”“dehydration”


O h l t “f f li ” tillO h l t “f f li ” tillOne hour later “funny feeling” still One hour later “funny feeling” still persistspersistsPallor recurs, patient becomes Pallor recurs, patient becomes diaphoreticdiaphoreticRepeat ECG is obtained…Repeat ECG is obtained…

Case 1 — Initial ECGCase 1 — Initial ECGCase 1 — Initial ECGCase 1 — Initial ECG


32 yo. man presents c/o chest pain and 32 yo. man presents c/o chest pain and y p / py p / pdyspneadyspnea●● Syncope one day priorSyncope one day priorSyncope one day priorSyncope one day prior●● Family history of early CADFamily history of early CAD●● RR 24 HR 110 BP 160/105RR 24 HR 110 BP 160/105●● RR 24, HR 110, BP 160/105RR 24, HR 110, BP 160/105●● ECG interpreted as “anterior and inferior ECG interpreted as “anterior and inferior

ischemia”ischemia”ischemiaischemia


Admitted to chest pain center for ACSAdmitted to chest pain center for ACS●● Treated with ASA, beta blockers, heparinTreated with ASA, beta blockers, heparin

Rules out for AMIRules out for AMI●● Persantine thallium test negativePersantine thallium test negative●● Mild dyspnea and tachypnea persistMild dyspnea and tachypnea persist●● Mild dyspnea and tachypnea persistMild dyspnea and tachypnea persist

attributed to “obesity and deconditioning”

●● ECG continues to show TECG continues to show T--wave abnormalitywave abnormality●● ECG continues to show TECG continues to show T wave abnormalitywave abnormalitynot addressed in chart


P ti t i di h d b t bl kP ti t i di h d b t bl kPatient is discharged on beta blockersPatient is discharged on beta blockersCardiac arrest 12 hours laterCardiac arrest 12 hours laterAutopsy confirms a Autopsy confirms a nonnon--cardiaccardiac cause…cause…


38 t / h t i38 t / h t i38 yo. woman presents c/o chest pain38 yo. woman presents c/o chest pain●● Only CRF is hypertensionOnly CRF is hypertension●● Pain worsens with deep inspiration or when Pain worsens with deep inspiration or when

laying back, improves sitting uprightlaying back, improves sitting uprightd dd d●● ECG interpreted as acute pericarditisECG interpreted as acute pericarditis


Intensive care physicians sees patient, Intensive care physicians sees patient, ith di i f i ditiith di i f i ditiagrees with diagnosis of pericarditisagrees with diagnosis of pericarditis

●● Patient is admitted to ICUPatient is admitted to ICU

First set of cardiac enzymes are normalFirst set of cardiac enzymes are normalSecond set of cardiac enzymes areSecond set of cardiac enzymes areSecond set of cardiac enzymes are Second set of cardiac enzymes are markedly elevatedmarkedly elevated●● Patient is emergently transferred for PTCAPatient is emergently transferred for PTCA●● Patient is emergently transferred for PTCAPatient is emergently transferred for PTCA

OutlineOutlineOutlineOutline

E l i l h i l d VLE l i l h i l d VL1.1. Early reciprocal changes in lead aVLEarly reciprocal changes in lead aVL2.2. Pulmonary Pulmonary embolism simulating ACSembolism simulating ACS3.3. Pericarditis Pericarditis vs. AMIvs. AMI44 Pericardial effusionsPericardial effusions4.4. Pericardial effusionsPericardial effusions

Normal ECGNormal ECGNormal ECGNormal ECG

Early Reciprocal Changes Early Reciprocal Changes in Lead aVLin Lead aVL

The normal ECG lead aVLThe normal ECG lead aVL●● Isoelectric STIsoelectric ST--segmentsegment●● Upright TUpright T--wavewave


The normal ECG lead aVLThe normal ECG lead aVL●● Isoelectric STIsoelectric ST--segmentsegment●● Upright TUpright T--wavewave

Acute inferior wall MIs Acute inferior wall MIs ●● Common “reciprocal changes”Common “reciprocal changes”p gp g

ST-segment downsloping in aVLT-wave inversion in aVL

Acute Inferior Wall MIAcute Inferior Wall MIAcute Inferior Wall MIAcute Inferior Wall MI


M i ttM i tt th i l VL hth i l VL hMarriott Marriott —— these reciprocal aVL changes these reciprocal aVL changes can can precede precede the development of inferior the development of inferior l d b litil d b litilead abnormalitieslead abnormalities


M i ttM i tt th i l VL hth i l VL hMarriott Marriott —— these reciprocal aVL changes these reciprocal aVL changes can can precede precede the development of inferiorthe development of inferiorl d b litil d b litilead abnormalitieslead abnormalities

Early Reciprocal Changes Early Reciprocal Changes in Lead aVL — Case 1in Lead aVL — Case 1

56 t / “th t56 t / “th t56 yo. man presents c/o “throat 56 yo. man presents c/o “throat burning,” nausea, and belchingburning,” nausea, and belching●● History of hypertension and tobacco useHistory of hypertension and tobacco use●● Treated in fastTreated in fast--track with Maalox/viscous track with Maalox/viscous

lid i ith ild i tlid i ith ild i tlidocaine with mild improvementlidocaine with mild improvement●● Patient wants to be dischargedPatient wants to be discharged


30 i t l t t30 i t l t t30 minutes later symptoms worsen 30 minutes later symptoms worsen ●● Now with diaphoresisNow with diaphoresis

ECG is obtainedECG is obtained●● Interpreted as normal (EP and cardiologist)Interpreted as normal (EP and cardiologist)


P ti t i i M l iP ti t i i M l iPatient is given Maalox againPatient is given Maalox again●● Symptoms persistSymptoms persist

Serial ECGs are then performed with Serial ECGs are then performed with the persistent symptoms…the persistent symptoms…


47 yo. man presents c/o of severe 47 yo. man presents c/o of severe fl t “ ll d ”fl t “ ll d ”reflux symptoms “all day”reflux symptoms “all day”

●● Belching, substernal burning, nauseaBelching, substernal burning, nausea●● History of prior septal MIHistory of prior septal MI●● No prior history of GERDNo prior history of GERD●● Symptoms improve significantly after Symptoms improve significantly after

Maalox and ranitidineMaalox and ranitidine●● ECG interpreted as “old septal MI, o/w ECG interpreted as “old septal MI, o/w

normal”normal”


Patient discharged feeling betterPatient discharged feeling betterg gg g●● Rx for ranitidineRx for ranitidine

Patient returns with recurrentPatient returns with recurrentPatient returns with recurrent Patient returns with recurrent symptoms 2 hours latersymptoms 2 hours laterECGECGECG…ECG…

ECG First VisitECG First VisitECG First VisitECG First Visit

ECG Second VisitECG Second VisitECG Second VisitECG Second Visit


46 t / b t l h t46 t / b t l h t46 yo. man presents c/o substernal chest 46 yo. man presents c/o substernal chest burning and diaphoresis after eating burning and diaphoresis after eating hi k f h lihi k f h lichicken soup few hours earlierchicken soup few hours earlier●● History of severe GERD, but History of severe GERD, but this was worsethis was worse●● Took prevacid, now feeling betterTook prevacid, now feeling better●● ECG interpreted as normal (EP and ECG interpreted as normal (EP and

d l )d l )cardiologist)cardiologist)


E h i i d id t bE h i i d id t bEmergency physician decides to observe Emergency physician decides to observe patient, draw labspatient, draw labs●● Pain worsens and serial ECGs demonstrate Pain worsens and serial ECGs demonstrate

progressive changesprogressive changes

70 yo man with CP70 yo man with CPECG: “non-specific ST/Ts"ECG: “non-specific ST/Ts"

70 yo man with CP70 yo man with CP(persisting after 1-2 hours)(persisting after 1-2 hours)

55 yo woman with atypical 55 yo woman with atypical CP (triage ECG)CP (triage ECG)

55 yo woman with atypical 55 yo woman with atypical CP (during evaluation)CP (during evaluation)

…later…cardiac arrest, …later…cardiac arrest, resus, cath 100% RCAresus, cath 100% RCA

73 yo man with atypical CP, 73 yo man with atypical CP, “non-specific Ts”“non-specific Ts”

Persistent pain…Persistent pain…40 min later40 min later


llNormal variantsNormal variants●● LBBBLBBB●● LVHLVH

Left Bundle Branch BlockLeft Bundle Branch BlockLeft Bundle Branch BlockLeft Bundle Branch Block

Left Ventricular HypertrophyLeft Ventricular HypertrophyLeft Ventricular HypertrophyLeft Ventricular Hypertrophy


R i l h i l d VL bR i l h i l d VL bReciprocal changes in lead aVL may be Reciprocal changes in lead aVL may be the first sign of inferior myocardial the first sign of inferior myocardial i h ii h iischemiaischemiaWhen in doubt, get serial ECGs!When in doubt, get serial ECGs!

The “Classic” PE ECGThe “Classic” PE ECGThe Classic PE ECGThe Classic PE ECG

ECG Findings in PEECG Findings in PEECG Findings in PEECG Findings in PE

SSIIQQIIIIII or Sor SIIQQIIIIIITTIIIIIIIIQQIIIIII IIQQIIIIII IIIIII

New RBBB or incomplete RBBBNew RBBB or incomplete RBBBRightward axisRightward axisRightward axisRightward axisSTST--segment elevations or depressionssegment elevations or depressions●● Less common, but important to know!Less common, but important to know!

TT--wave inversions, especially wave inversions, especially anteroseptal anteroseptal ++ inferior leadsinferior leads


TT--wave inversions, especially wave inversions, especially , p y, p yanteroseptal anteroseptal ++ inferior leadsinferior leads●● Common in cases of large PECommon in cases of large PECommon in cases of large PECommon in cases of large PE●● 3030--50% sensitivity50% sensitivity


TT--wave inversions, especially wave inversions, especially , p y, p yanteroseptal + inferior leadsanteroseptal + inferior leads


TT--wave inversions, especially wave inversions, especially , p y, p yanteroseptal + inferior leadsanteroseptal + inferior leads●● MarriottMarriott Highly specific for PEHighly specific for PEMarriott Marriott Highly specific for PEHighly specific for PE●● Kosuge (Am J Cardiol 2007)Kosuge (Am J Cardiol 2007)

99% specific for PE!p

PE Simulating ACS —PE Simulating ACS —Case 1Case 1

33 yo. man presents c/o progressive 33 yo. man presents c/o progressive dyspnea during the past weekdyspnea during the past weekdyspnea during the past weekdyspnea during the past week●● History of History of massivemassive obesity and CHFobesity and CHF

d “d ”d “d ”●● Lungs sounds “distant”Lungs sounds “distant”●● CXR read in ED as c/w pulmonary edemaCXR read in ED as c/w pulmonary edema

official reading: “CMG, clear fields”


33 yo. man presents c/o progressive 33 yo. man presents c/o progressive dyspnea during the past weekdyspnea during the past weekdyspnea during the past weekdyspnea during the past week●● History of History of massivemassive obesity and CHFobesity and CHF

d “d ”d “d ”●● Lungs sounds “distant”Lungs sounds “distant”●● CXR read in ED as c/w pulmonary edemaCXR read in ED as c/w pulmonary edema

official reading: “CMG, clear fields”

●● ECG interpreted as showing “cardiac ECG interpreted as showing “cardiac ischemia”ischemia”ischemia”ischemia”

cardiologist: “Anterior-inferior ischemia.”


Patient is treated for CHF with nitrates Patient is treated for CHF with nitrates d f idd f idand furosemideand furosemide

●● ECG remains unchangedECG remains unchanged

Rules out for AMIRules out for AMIPatient is discharged feeling betterPatient is discharged feeling betterg gg g


Patient has cardiac arrest next dayPatient has cardiac arrest next dayAutopsy performed Autopsy performed ●● Large saddle embolus and 2 other PEsLarge saddle embolus and 2 other PEs●● No evidence of CAD No evidence of CAD


81 yo. woman presents c/o dyspnea for 81 yo. woman presents c/o dyspnea for y p / y py p / y p3 days3 days●● History includes COPDHistory includes COPDHistory includes COPDHistory includes COPD●● Exam is notable for poor breath sounds and Exam is notable for poor breath sounds and

scant wheezes (chronic per records)scant wheezes (chronic per records)( p )( p )


81 yo. woman presents c/o dyspnea for 81 yo. woman presents c/o dyspnea for y p / y py p / y p3 days3 days●● History includes COPDHistory includes COPDHistory includes COPDHistory includes COPD●● Exam is notable for poor breath sounds and Exam is notable for poor breath sounds and

scant wheezes (chronic per records)scant wheezes (chronic per records)( p )( p )●● ECG interpreted as anterior and inferior ECG interpreted as anterior and inferior

ischemiaischemia


ED treatment focuses on COPD and ACSED treatment focuses on COPD and ACS●● Nebulizers, steroids, aspirinNebulizers, steroids, aspirin

Cardiac enzymes are sentCardiac enzymes are sentCardiac enzymes are sentCardiac enzymes are sentPatient rules out for MIPatient rules out for MID i b h d bD i b h d bDyspnea improves by the next day, but…Dyspnea improves by the next day, but…


ED treatment focuses on COPD and ACSED treatment focuses on COPD and ACS●● Nebulizers, steroids, aspirinNebulizers, steroids, aspirin

Cardiac enzymes are sentCardiac enzymes are sentCardiac enzymes are sentCardiac enzymes are sentPatient rules out for MIPatient rules out for MID i b h d bD i b h d bDyspnea improves by the next day, but…Dyspnea improves by the next day, but…●● Patient has a cardiac arrest and diesPatient has a cardiac arrest and dies●● Autopsy shows massive PEAutopsy shows massive PE


51 yo. woman presents c/o dyspnea at 51 yo. woman presents c/o dyspnea at y p / y py p / y prest and with exertion, orthopnea, rest and with exertion, orthopnea, cough productive of clear sputumcough productive of clear sputumg p pg p p●● History of MI, diabetes, CHF, smokerHistory of MI, diabetes, CHF, smoker●● Normal oxygen saturation, CXRNormal oxygen saturation, CXR●● Normal oxygen saturation, CXRNormal oxygen saturation, CXR


51 yo. woman presents c/o dyspnea at 51 yo. woman presents c/o dyspnea at y p / y py p / y prest and with exertion, orthopnea, rest and with exertion, orthopnea, cough productive of clear sputumcough productive of clear sputumg p pg p p●● History of MI, diabetes, CHF, smokerHistory of MI, diabetes, CHF, smoker●● Normal oxygen saturation, CXRNormal oxygen saturation, CXR●● Normal oxygen saturation, CXRNormal oxygen saturation, CXR●● ECG interpreted as “inferior and anterior ECG interpreted as “inferior and anterior

ischemic changes”ischemic changes”gg●● Admitted for CHF (?) and ACSAdmitted for CHF (?) and ACS


Patient rules out for AMIPatient rules out for AMIDevelops wheezing prior to stress testDevelops wheezing prior to stress test●● No prior history of reactive airway diseaseNo prior history of reactive airway disease●● No prior history of reactive airway diseaseNo prior history of reactive airway disease

Lung CT is performedLung CT is performedM lti l PEM lti l PE●● Multiple PEsMultiple PEs

PE Simulating ACS —PE Simulating ACS —Case 4 Case 4

50 yo. man presents with severe 50 yo. man presents with severe y py psubsternal chest pain radiating to left substernal chest pain radiating to left upper chest, dyspnea, diaphoresisupper chest, dyspnea, diaphoresispp , y p , ppp , y p , p●● No cardiac risk factorsNo cardiac risk factors●● Exam is notable only for tachycardia (HRExam is notable only for tachycardia (HR●● Exam is notable only for tachycardia (HR Exam is notable only for tachycardia (HR

137) and tachypnea (RR 22)137) and tachypnea (RR 22)

PE Simulating ACS —PE Simulating ACS —Case 4 Case 4

50 yo. man presents with severe 50 yo. man presents with severe y py psubsternal chest pain radiating to left substernal chest pain radiating to left upper chest, dyspnea, diaphoresisupper chest, dyspnea, diaphoresispp , y p , ppp , y p , p●● No cardiac risk factorsNo cardiac risk factors●● Exam is notable only for tachycardiaExam is notable only for tachycardia●● Exam is notable only for tachycardia Exam is notable only for tachycardia

(HR 137) and tachypnea (RR 22)(HR 137) and tachypnea (RR 22)●● ECG interpreted as showing inferior and ECG interpreted as showing inferior and p gp g

anterior ischemiaanterior ischemia


Patient is treated with ASA NTG heparinPatient is treated with ASA NTG heparinPatient is treated with ASA, NTG, heparinPatient is treated with ASA, NTG, heparin●● Chest pain persistsChest pain persists

Cardiologist is consultedCardiologist is consultedCardiologist is consultedCardiologist is consulted●● Recommends addition of metoprolol, Recommends addition of metoprolol,

clopidogrel eptifibitide and morphineclopidogrel eptifibitide and morphineclopidogrel, eptifibitide, and morphineclopidogrel, eptifibitide, and morphine


Patient is treated with ASA NTG heparinPatient is treated with ASA NTG heparinPatient is treated with ASA, NTG, heparinPatient is treated with ASA, NTG, heparin●● Chest pain persistsChest pain persists

Cardiologist is consultedCardiologist is consultedCardiologist is consultedCardiologist is consulted●● Recommends addition of metoprolol, Recommends addition of metoprolol,

clopidogrel eptifibitide and morphineclopidogrel eptifibitide and morphineclopidogrel, eptifibitide, and morphineclopidogrel, eptifibitide, and morphine●● Arranges transfer for emergent cardiac Arranges transfer for emergent cardiac

catheterizationcatheterizationcatheterizationcatheterization


C th t i ti h i ifi t CADC th t i ti h i ifi t CADCatheterization shows no significant CADCatheterization shows no significant CADPain free with morphinePain free with morphineRules out for AMIRules out for AMIAll cardiac medications are discontinuedAll cardiac medications are discontinuedAll cardiac medications are discontinuedAll cardiac medications are discontinued●● No further workup for cause of chest painNo further workup for cause of chest painPatient is dischargedPatient is dischargedPatient is dischargedPatient is discharged


P ti t f ll ith i iti l di l i tP ti t f ll ith i iti l di l i tPatient follows up with initial cardiologistPatient follows up with initial cardiologistStill complaining of dyspnea, especially Still complaining of dyspnea, especially with exertionwith exertionRepeat ECG shows persistent TWIsRepeat ECG shows persistent TWIsp pp pCardiologist orders further studies…Cardiologist orders further studies…


VQVQ “ iti ”“ iti ”VQ VQ “positive”“positive”LE U/S LE U/S positivepositive


25 yo. woman presents with chest 25 yo. woman presents with chest ti ht d dti ht d dtightness and dyspneatightness and dyspnea●● 12 weeks pregnant12 weeks pregnant●● History of asthmaHistory of asthma


25 yo. woman presents with chest 25 yo. woman presents with chest ti ht d dti ht d dtightness and dyspneatightness and dyspnea●● 12 weeks pregnant12 weeks pregnant●● History of asthmaHistory of asthma●● Exam notable for tachycardia, mild Exam notable for tachycardia, mild

wheezing, mild chest tenderness; legs wheezing, mild chest tenderness; legs normalnormal


25 yo. woman presents with chest 25 yo. woman presents with chest ti ht d dti ht d dtightness and dyspneatightness and dyspnea●● 12 weeks pregnant12 weeks pregnant●● History of asthmaHistory of asthma●● Exam notable for tachycardia, mild Exam notable for tachycardia, mild

wheezing, mild chest tenderness; legs wheezing, mild chest tenderness; legs normalnormalCG i d “fli d lik lCG i d “fli d lik l●● ECG interpreted as “flipped T waves, likely ECG interpreted as “flipped T waves, likely

nonspecific given her age”nonspecific given her age”


Patient improves with nebulizer therapyPatient improves with nebulizer therapyp pyp pyPatient is discharged homePatient is discharged homeCardiac arrest 12 hours laterCardiac arrest 12 hours laterCardiac arrest 12 hours laterCardiac arrest 12 hours later●● Autopsy confirms multiple PEs, saddle Autopsy confirms multiple PEs, saddle

embolus large DVTembolus large DVTembolus, large DVTembolus, large DVT

PE Simulating ACS —PE Simulating ACS —Summary Summary

P l b li ECGP l b li ECGPulmonary embolism can cause ECG Pulmonary embolism can cause ECG changes that simulate ACSchanges that simulate ACS


P l b li ECGP l b li ECGPulmonary embolism can cause ECG Pulmonary embolism can cause ECG changes that simulate ACSchanges that simulate ACS●● Strongly consider PE when the ECG has Strongly consider PE when the ECG has

inverted Tinverted T--waves simultaneously in the waves simultaneously in the anteroseptal + inferior leadsanteroseptal + inferior leadsanteroseptal + inferior leadsanteroseptal + inferior leads


P l b li ECGP l b li ECGPulmonary embolism can cause ECG Pulmonary embolism can cause ECG changes that simulate ACSchanges that simulate ACS●● Strongly consider PE when the ECG has Strongly consider PE when the ECG has

inverted Tinverted T--waves simultaneously in the waves simultaneously in the anteroseptal + inferior leadsanteroseptal + inferior leadsanteroseptal + inferior leadsanteroseptal + inferior leads

●● Once you’ve ruled out ACS in the chest Once you’ve ruled out ACS in the chest pain patientpain patient you’re still not done!!you’re still not done!!pain patient, pain patient, you re still not done!!you re still not done!!

OutlineOutlineOutlineOutline

1.1. Reciprocal changes in lead aVLReciprocal changes in lead aVL2.2. Pulmonary embolism simulating ACSPulmonary embolism simulating ACSy gy g3.3. Pericarditis vs. AMIPericarditis vs. AMI

PericarditisPericarditisPericarditisPericarditis

Cl i t hiCl i t hiClassic teachingClassic teaching●● Diffuse STDiffuse ST--segment elevationsegment elevation

STST t l ti i dt l ti i d●● STST--segment elevation is concave upwardssegment elevation is concave upwards


Cl i t hiCl i t hiClassic teachingClassic teaching●● PRPR--segment depression (downsloping)segment depression (downsloping)

PRPR t l ti i VRt l ti i VR●● PRPR--segment elevation in aVRsegment elevation in aVR


Cl i t hiCl i t hiClassic teachingClassic teaching●● Chest pain tends to be positional, pleuriticChest pain tends to be positional, pleuritic

F i ti bF i ti b●● Friction rubFriction rub



STST t l ti i dt l ti i d●● STST--segment elevation is concave upwardssegment elevation is concave upwards



may be localized instead of diffusepearl no reciprocal ST-segment depression!

STST t l ti i dt l ti i d●● STST--segment elevation is concave upwardssegment elevation is concave upwardsAMI may have similar ST-segment morphologypearl ST segment elevation that is convexpearl ST-segment elevation that is convex upwards or horizontal strongly favors AMI


Additi l l STEAdditi l l STEAdditional pearl: STEAdditional pearl: STE●● STE II > STE III strongly favors pericarditisSTE II > STE III strongly favors pericarditis●● STE III > STE II STE III > STE II veryvery strongly favors AMIstrongly favors AMI


Cl i t hiCl i t hiClassic teachingClassic teaching●● PRPR--segment depression (downsloping)segment depression (downsloping)

primarily present in viral pericarditisoften an early, transient finding

PRPR t l ti i VRt l ti i VR●● PRPR--segment elevation in aVRsegment elevation in aVRmay also be present in other diseases (e.g. AMI)often absent in constrictive pericarditisoften absent in constrictive pericarditis


Cl i t hiCl i t hiClassic teachingClassic teaching●● Chest pain tends to be positional, pleuriticChest pain tends to be positional, pleuritic

16% of AMIs may present with positional or pleuritic pain

Friction rubFriction rub●● Friction rubFriction ruboften transient

ECGs and PericarditisECGs and PericarditisECGs and PericarditisECGs and Pericarditis

1.1. Factors that ruleFactors that rule--inin STEMISTEMI●● STD except in V1 or aVRSTD except in V1 or aVR●● STD except in V1 or aVRSTD except in V1 or aVR

(STD in V1 or aVR is normal in many patients)●● STE in III > IISTE in III > II●● Horizontal or convex upwards STEHorizontal or convex upwards STE●● QQ--waves that you waves that you knowknow are neware new



(STD in V1 or aVR is normal in many patients)●● STE in III > IISTE in III > II●● Horizontal or convex upwards STEHorizontal or convex upwards STE●● QQ--waves that you waves that you knowknow are neware newF t th t t APF t th t t AP2.2. Factors that suggest APFactors that suggest AP●● Friction rubFriction rub●● PR depression inPR depression in multiplemultiple leadsleads●● PR depression in PR depression in multiplemultiple leadsleads

(Only reliably seen in viral percarditis, transient)


Wh i d bt tWh i d bt tWhen in doubt, get When in doubt, get i l ECG !i l ECG !serial ECGs!serial ECGs!

STEMI or AP?STEMI or AP?STEMI or AP?STEMI or AP?

Summary —STEMI P i di i

Summary —STEMI P i di iSTEMI vs. PericarditisSTEMI vs. Pericarditis


(STD in V1 or aVR is normal in many patients)●● STE in III > IISTE in III > II●● Horizontal or convex upwards STEHorizontal or convex upwards STE●● QQ--waves that you waves that you knowknow are neware new




(STD in V1 or aVR is normal in many patients)●● STE in III > IISTE in III > II●● Horizontal or convex upwards STEHorizontal or convex upwards STE●● QQ--waves that you waves that you knowknow are neware newF t th t t APF t th t t AP2.2. Factors that suggest APFactors that suggest AP●● Friction rubFriction rub●● PR depression inPR depression in multiplemultiple leadsleads●● PR depression in PR depression in multiplemultiple leadsleads

(Only reliably seen in viral pericarditis, transient)



Wh i d bt tWh i d bt tWhen in doubt, get When in doubt, get i l ECG !i l ECG !serial ECGs!serial ECGs!

Review of Initial CasesReview of Initial CasesReview of Initial CasesReview of Initial Cases

R i l h i l d VLR i l h i l d VL1.1. Reciprocal changes in lead aVLReciprocal changes in lead aVL2.2. Pulmonary embolism simulating ACSPulmonary embolism simulating ACS3.3. Pericarditis Pericarditis vs. vs. AMIAMI


87 b87 b87 yo. man became nauseous, 87 yo. man became nauseous, diaphoretic, and pale while in churchdiaphoretic, and pale while in church●● No chest pain or dyspneaNo chest pain or dyspnea●● “Funny feeling under my chest”“Funny feeling under my chest”●● ECG interpreted as normal in EDECG interpreted as normal in ED●● Cardiologist reads “NSC from previous Cardiologist reads “NSC from previous

ECG” (4 years earlier)ECG” (4 years earlier)


Patient’s nausea is treated with Patient’s nausea is treated with antiemeticsantiemeticsPallor resolves with IVFPallor resolves with IVFPallor resolves with IVFPallor resolves with IVFSL NTG has no effect on “funny feeling” SL NTG has no effect on “funny feeling” in chestin chestin chestin chest●● No further interventions/treatmentNo further interventions/treatment

Pl d f d i i fPl d f d i i fPlans are made for admission for Plans are made for admission for “dehydration”“dehydration”


O h l t “f f li ” tillO h l t “f f li ” tillOne hour later “funny feeling” still One hour later “funny feeling” still persistspersistsPallor recurs, patient becomes Pallor recurs, patient becomes diaphoreticdiaphoreticRepeat ECG is obtained…Repeat ECG is obtained…

Case 1 — Initial ECGCase 1 — Initial ECGCase 1 — Initial ECGCase 1 — Initial ECG


32 yo. man presents c/o chest pain and 32 yo. man presents c/o chest pain and y p / py p / pdyspneadyspnea●● Syncope one day priorSyncope one day priorSyncope one day priorSyncope one day prior●● Family history of early CADFamily history of early CAD●● RR 24 HR 110 BP 160/105RR 24 HR 110 BP 160/105●● RR 24, HR 110, BP 160/105RR 24, HR 110, BP 160/105●● ECG interpreted as “anterior and inferior ECG interpreted as “anterior and inferior

ischemia”ischemia”ischemiaischemia


Admitted to chest pain center for ACSAdmitted to chest pain center for ACS●● Treated with ASA, beta blockers, heparinTreated with ASA, beta blockers, heparin

Rules out for AMIRules out for AMI●● Persantine thallium test negativePersantine thallium test negative●● Mild dyspnea and tachypnea persistMild dyspnea and tachypnea persist●● Mild dyspnea and tachypnea persistMild dyspnea and tachypnea persist

attributed to “obesity and deconditioning”

●● ECG continues to show TECG continues to show T--wave abnormalitywave abnormality●● ECG continues to show TECG continues to show T wave abnormalitywave abnormalitynot addressed in chart


P ti t i di h d b t bl kP ti t i di h d b t bl kPatient is discharged on beta blockersPatient is discharged on beta blockersCardiac arrest 12 hours laterCardiac arrest 12 hours laterAutopsy confirms a Autopsy confirms a nonnon--cardiaccardiac cause…cause…


38 t / h t i38 t / h t i38 yo. woman presents c/o chest pain38 yo. woman presents c/o chest pain●● Only CRF is hypertensionOnly CRF is hypertension●● Pain worsens when laying back, improves Pain worsens when laying back, improves

sitting uprightsitting uprightd dd d●● ECG interpreted as acute pericarditisECG interpreted as acute pericarditis


Intensive care physicians sees patient, Intensive care physicians sees patient, ith di i f i ditiith di i f i ditiagrees with diagnosis of pericarditisagrees with diagnosis of pericarditis

●● Patient is admitted to ICUPatient is admitted to ICU

First set of cardiac enzymes are normalFirst set of cardiac enzymes are normalSecond set of cardiac enzymes areSecond set of cardiac enzymes areSecond set of cardiac enzymes are Second set of cardiac enzymes are markedly elevatedmarkedly elevated●● Patient is emergently transferred for PTCAPatient is emergently transferred for PTCA●● Patient is emergently transferred for PTCAPatient is emergently transferred for PTCA

SummarySummarySummarySummary

Reciprocal changes in lead aVL may beReciprocal changes in lead aVL may beReciprocal changes in lead aVL may be Reciprocal changes in lead aVL may be the first sign of inferior myocardial the first sign of inferior myocardial ischemiaischemiaischemiaischemiaWhen in doubt, get serial ECGs!When in doubt, get serial ECGs!


Pulmonary embolism can cause ECGPulmonary embolism can cause ECGPulmonary embolism can cause ECG Pulmonary embolism can cause ECG changes that simulate ACSchanges that simulate ACS●● Strongly consider PE when the ECG hasStrongly consider PE when the ECG has●● Strongly consider PE when the ECG has Strongly consider PE when the ECG has

inverted Tinverted T--waves simultaneously in the waves simultaneously in the anteroseptal + inferior leadsanteroseptal + inferior leadspp

●● Once you’ve ruled out ACS in the chest Once you’ve ruled out ACS in the chest pain patient, you’re still not done!!pain patient, you’re still not done!!


Pericarditis is often not “classic!”Pericarditis is often not “classic!”Very strongly favoring AMIVery strongly favoring AMI●● Very strongly favoring AMIVery strongly favoring AMI

reciprocal changesconvex upwards or horizontal STEconvex upwards or horizontal STESTE in III > IInew Q-wavesQ


Pericarditis is often not “classic!”Pericarditis is often not “classic!”Very strongly favoring AMIVery strongly favoring AMI●● Very strongly favoring AMIVery strongly favoring AMI

reciprocal changesconvex upwards or horizontal STEconvex upwards or horizontal STESTE in III > IInew Q-wavesQ

●● Very strongly favoring pericarditisVery strongly favoring pericarditispronounced PR-segment depressions in p g pmultiple leadsfriction rub

RememberRememberRemember…Remember…

J t b l t di h iJ t b l t di h iJust because electrocardiography is Just because electrocardiography is a basic skill in EM doesn’t mean a basic skill in EM doesn’t mean that our skills should be that our skills should be basicbasic..YOUYOU must bemust be the expertsthe experts ininYOU YOU must be must be the expertsthe experts in in electrocardiography!electrocardiography!

subtle manifestations of deadly cardiac...

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