ECG Case 11: A 45 year old man with vague chest pain

Acute pericarditis is a condition characterized by inflammation of the pericardium, the sac surrounding the heart. This inflammation can lead to a range of symptoms, including chest pain, fever, and fatigue. One of the key diagnostic tools for acute pericarditis is the electrocardiogram (ECG), which can reveal a number of characteristic changes.

In the early stages of acute pericarditis, the ECG may show a pattern of widespread ST-segment elevation. This is often accompanied by a slight elevation of the PR segment, and a decrease in the amplitude of the QRS complex. The ST-segment elevation is typically concave upwards, and may be seen in all leads except aVR. This pattern of ST-segment elevation is often referred to as a "saddle-shaped" or "dome-shaped" appearance.

As the condition progresses, the ECG may show a number of additional changes. One of the most characteristic features of acute pericarditis is the development of PR-segment depression. This is often seen in leads I, II, and aVL, and may be accompanied by a slight elevation of the PR segment in lead aVR. The PR-segment depression is thought to be due to the inflammation of the pericardium, which can affect the atrial myocardium.

In some cases, the ECG may also show a pattern of T-wave inversion. This is often seen in the anterior leads (V2-V4), and may be accompanied by a slight elevation of the T-wave in lead aVL. The T-wave inversion is thought to be due to the resolution of the inflammatory process, and may be seen as the condition begins to resolve.

It's worth noting that the ECG changes seen in acute pericarditis can be quite subtle, and may be easily overlooked. In addition, the ECG may not always show the characteristic changes described above. Therefore, a high index of suspicion is needed to diagnose acute pericarditis, and a combination of clinical evaluation, laboratory tests, and imaging studies may be needed to confirm the diagnosis.

In terms of differential diagnosis, the ECG changes seen in acute pericarditis can be similar to those seen in other conditions, such as acute myocardial infarction or pulmonary embolism. However, the presence of widespread ST-segment elevation, PR-segment depression, and T-wave inversion can help to distinguish acute pericarditis from these other conditions.

In conclusion, the ECG is a valuable tool in the diagnosis of acute pericarditis. The characteristic changes seen on the ECG, including widespread ST-segment elevation, PR-segment depression, and T-wave inversion, can help to confirm the diagnosis and distinguish it from other conditions. However, a high index of suspicion is needed, and a combination of clinical evaluation, laboratory tests, and imaging studies may be needed to confirm the diagnosis.

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