Friday, April 19, 2019

A Young Man with Sharp Chest pain


Suppose this patient had chest pain.  What would you diagnose?


What is the diagnosis?

















OK.  I lied, just so you could assess your reaction to this ECG.

In fact, this patient did NOT have chest pain.  But some day he may show up in an ED with chest wall pain, and he might erroneously be diagnosed with pericarditis.

This is just classic early repol.  This was recorded in an 18 year old otherwise healthy young man who just had a seizure.  There were no chest symptoms at all.  This was his baseline ECG.

Notice:

1. There is diffuse ST elevation, in all myocardial territories.
2. STE is greater in lead II than III
3. There is no reciprocal ST depression, especially none in aVL
4. There is some PR depression, but less than 0.5 mm
5. Spodick's sign is present
6. There are prominent J-waves in almost every lead.

ECGs like this are often attributed to pericarditis, when the vast majority of the time they are simply normal early repolarization.

Here is a great case where such bias led to poor management:

31 Year Old Male with RUQ Pain and a History of Pericarditis. Submitted by a Med Student, with Great Commentary on Bias!



It is true that early repolarization, as defined by J-waves in inferior and lateral leads, is associated with a higher long term risk of ventricular fibrillation.  But it has no bearing on ED management.




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Comment by KEN GRAUER, MD (4/19/2019):
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My initial impression on seeing the ECG posted in this case (which I’ve reproduced for clarity in Figure-1) — was that despite the history we were given ( = chest pain) — that the tracing most probably represented Early Repolarization. That said — I was admittedly not 100% certain of this. I’ll explain my thought process by use of 4 words: iHistoryiiRubiiiProportionalityandivSuperimposition.

Figure-1: The ECG posted in this case (See text).
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My thought process:
  • The HISTORY: There’s a lot to the history when considering acute pericarditis — including age of the patient — clinical likelihood of acute viral pericarditis ( = by far, the most common cause of acute pericarditis in an ED or out-patient centervs pericarditis secondary to some other underlying disorder — and, the specific nature of the type of chest pain that the patient is having. I’ve summarized some factors to consider in this regard in Figure-2.
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Figure-2: Factors to consider in obtaining the history in a patient who might have acute pericarditis (Excerpted from Grauer K: ECG-2014-ePub).
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  • The RUB: During the past 9+ years that I’ve been interpreting too-numerous-to-count ECGs on a daily basis on various internet ECG forums — the overwhelming majority (I’d estimate well over 90%) of ECG cases posted in which acute pericarditis is a diagnostic consideration, fail to even mention cardiac auscultation in listening for detection of a pericardial friction rub. When the pertinent negative of “No rub heard” is not even mentioned in the clinical presentation — it usually means that the clinician did not specifically listen for a rub. While true that acute pericarditis may not necessarily manifest an audible rub at the time you examine the patient — sometimes it does !!! And, IF you are able to hear a definite pericardial friction rub — then you have made a definitive diagnosis within seconds.
Figure-3: Factors to consider regarding physical examination in a patient who might have acute pericarditis (Excerpted from Grauer K: ECG-2014-ePub).
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  • PROPORTIONALITY: The numerical amount of ST elevation seen in multiple leads in Figure-1 is impressive (many leads showing ≥3-4mm of ST elevation). That said — when you consider the markedly increased QRS amplitude evident in so many leads (which I have counted and noted in BLUE letters) — proportionally, the relative amount of ST elevation in Figure-1 is not that great. Together with the prominent J-point notching we see in so many leads — the appearance of ST-T waves in this tracing could be perfectly consistent with a repolarization abnormality.
  • SUPERIMPOSITION: One factor that I see all-too-often-ignored — is that a patient may start out with an early repolarization picture — and superimposed on this, then develop a case of acute pericarditis. I have NO idea how to rule out this possibility simply by looking at the ECG shown in Figure-1. Finding a prior ECG on the patient may help — but the caveat exists that ST-T wave changes of early repolarization may vary when serial ECGs are obtained. This is why without considering the other factors mentioned above — I would not be 100% certain that the ECG in Figure-1 was simply a repolarization variant. This ECG certainly has many features consistent with a repolarization variant — and acute pericarditis is a far less common entity. But more than just a single ECG is needed when the goal is to be sure that the patient does not have pericarditis.



3 comments:

  1. Nebwie prehospital dx ... How does one differentiate between early repolarisation and pericarditis?

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    Replies
    1. See Ken Grauer above. Most important is that pericarditis is rare and early repol is common. Pericarditis should not be diagnosed from the EKG alone. Should have rub, effusion, or absence of wall motion abnormality. If everything is normal, it could be pericarditis, but more likely chest wall pain

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  2. The term "J wave" is reserved for Osborn wave of hypothermia, the slurred downstroke of the QRS. I would describe the finding at the J point of this entity, early repolarization, as "notched"
    K. Wang.

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