A Patient ECG Case: ST Elevation - Always Listen to History and Look Closely at ECG!

A 68 year old male presents to emergency with 2 days of central chest pain. The pain is sharp and radiating to both shoulders. It improves with sitting up and worsens with lying flat. It previously was worse with deep breaths, though not anymore. It currently is just a dull ache. His granddaughter had a viral infection recently, but the patient himself denies any viral symptoms. 

The ECG was as follows:

There is sinus tachycardia, ST elevation in leads I, aVL, V2-6 and also in lead II. PR segment is elevated in aVR and depressed in II and V2-6. 

The patient was not taken to the cath lab since the story and ECG are quite typical of acute viral pericarditis. He was prescribed ibuprofen 600mg q8h, to taper according to symptom relief, colchicine 0.6mg twice daily for 3 months and a PPI for gut protection. 

Characteristic Changes of Acute Pericarditis:

• PR segment depression.

• Widespread concave ST elevation. 

• Reciprocal ST depression and PR elevation in aVR.

• Absence of reciprocal ST depression. 

Causes of Pericarditis:

• Viral infections (most common).

• Bacterial infections.

• Post-cardiac injury syndromes.

• Autoimmune disorders.

• Uremia.

• Neoplastic diseases.

Incidence:

• More common in males.

• Peak incidence in 20-50 age group.

• Represents 5% of ER visits for chest pain with normal coronary arteries.

Medical Therapy:

• NSAIDs (e.g., ibuprofen) for pain and inflammation.

• Colchicine to reduce recurrence risk.

• Corticosteroids for severe cases.

• Treating underlying cause if identified.

Prognosis:

• Generally favorable with treatment.

• Recurrence in up to 30% of cases.

• Rare complications like constrictive pericarditis or cardiac tamponade.

Risk of Pericardial Tamponade:

• Pericardial tamponade is a rare but serious complication.

• Frequency in viral pericarditis is low, but vigilance is necessary.

Diagnosis of Tamponade:

• Clinical signs include sinus tachycardia.

• Hypotension, muffled heart sounds, and jugular venous distention (Beck's triad).

• Pulsus paradoxus (exaggerated decrease in systolic blood pressure during inspiration).

Echocardiogram is the diagnostic modality of choice, showing accumulation of pericardial fluid and diastolic collapse of cardiac chambers.