ECG rounds Nov 13/03
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Transcript of ECG rounds Nov 13/03
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ECG rounds Nov 13/03
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26 year old soccer player retrosternal chest pain. visiting from Egypt and did not speak English. A
friend gives a limited history. acute onset of chest pain earlier that morning.
6/10 The pain radiated into his neck and both arms. associated nausea, vomiting, presyncope, +
diaphoresis.
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Further history
No history of similar sx, recent illnesses, or trauma.
Medical, surgical, and family history unremarkable. He was taking no regular no meds, no rec drugs
smoker 10 pack years He denied risk factors for the HIV and any
history of exposure to tuberculosis.
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Physical exam
130/90 mm Hg in both arms, HR 106 RR 32, 37.5 sat 98% on RA
moderate distress unable to lie flat on the gurney.
His lungs are clear, and auscultation of the heart reveals only tachycardia. The rest of the physical exam was normal.
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pericarditis
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Pericarditis 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
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Four StagesFirst 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 weeks3. 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.
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Pericarditis vs Infarction Common characteristics
– retrosternal or precordial with radiation to the neck, back, left shoulder or arm
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 NO evolution of Q waves PR Segment Depression T Wave inversion after ST
segments return to baseline
Concave upward ST Elevation
ST Elevation in all leads except aVR ± V1
MI Q waves may evolve Not seen unless Atrial
infarct T Waves invert as ST
segments elevate Convex ST Elevation ST Elevation coincides to
specific coronary territory
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Early repolarization most common in teenaged boys and men
in their 20s. the clinical syndrome of pain and dyspnea
is absent ECG does not, over time, evolve a pattern
of return of the ST segment to baseline followed by T-wave inversion
prior ECG may be helpful
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Lead V6
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Pericarditis MI Early repolarizationST concave convex concave
ST:T in V6 >0.25 N/A <0.25
Reciprocalchanges
absent present absent
ST elevlocation
limb andprecordial
area ofartery
precordial leads
Q waves absent present absent
PRdepression
present absent absent
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ECG differential
CVA Pulmonary Embolus Pneumothorax Pneumopericardium Subepicardial
hemorrhage
ECG AMI Early Repolarization Myocarditis Hyperkalemia Ventricular Aneurysm Normal Variant
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Causes of pericarditis Idiopathic (75-80%) Viral, bacterial, TB, fungal,
rickettsia, parasitic, endocarditis
Post Radiation Neoplastic Post MI (us. large infarct) Infarction pericarditis Trauma Dissecting Aneurysm
SLE, RA, vasculitis, scleroderma
Wegener’s, PAN, sarcoid, Crohn’s/UC, Behcet’s
Drug Induced: Procainamide, INH, hydralazine
Hypothyroidism Renal Failure/Uremia Chylopericardium
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Common causes
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, varicella-zoster, influenza, Epstein-Barr, HIV, adenovirus, echovirus
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Common causes Inpatient setting
T = Trauma, TUMORU = UremiaM = Myocardial infarction (acute, post)
Medications (hydralazine, procainamide)O = Other infections (Staph, Strep pneumo, Hemophilus, meningococcus, TB, fungal)R = Rheumatoid, autoimmune disorder,
Radiation
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Management
The goals of therapy are relief of pain and resolution of inflammation and effusion
Treat underlying cause In most patients, therapy should be
initiated with aspirin or an NSAID Follow-up within one week is appropriate Consider follow up ECG at 4 weeks but...
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Back to the first case
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.
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References 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.hypertension-consult.com/Secure/textbookarticles/Textbook/58_ECG2.htm
Harrison’s Online Medslides.com