PR-segment Depression Research Articles

Differential Diagnosis Clinical Presentation and Minimal Risk Factors – ST Segment Elevation Myocardial Infarction vs Myopericarditis: A Case Report

The condition of STEMI (ST Segment Elevation Myocardial Infarction) can resemble infectious diseases of the heart such as Myopericarditis with the presence of dominant gastrointestinal symptoms, minimal demographic characteristics and cardiovascular risk factors as well as limited supporting examinations, making it a challenge in determining the diagnosis of cardiovascular disease. Case Report: 31 year old male with complaints of pain in the pit of the stomach that was difficult to describe and discomfort that extended to the chest that was not specific, a history of fever for 2 days, nausea and vomiting and a history of the habit of only consuming alcohol without smoking and the patient doing routine physical activities. ECG examination showed sinus rhythm with ST segment elevation in the precordial (anterior and lateral), inferior and LAD (Left Axis Deviation) leads as well as PR segment depression, Troponin I increased and Echocardiography showed a hypokinetic pattern in the posterior and septal segments of the heart. Fibrinolytics improved the patient's symptoms but not serial EKGs, giving rise to suspicion of STEMI which resembles Myopericarditis. Conclusion: Differential diagnosis with the possibility of myopericarditis was based on clinical findings and minimal risk factors, history of the course of the disease, ECG examination, Cardiac Biomarkers, TTE and Coronary Angiography. The patient underwent a Coronary Angiography examination with normal results, thereby ruling out a diagnosis of STEMI. The diagnostic overlap between STEMI and Myopericarditis was difficult to evaluate.

Abstract 18155: A Rare Case of Acute Purulent Pericarditis Secondary to Invasive Streptococcal Infection (S. Pyogenes) With Cardiac Tamponade in an Immunocompetent 37-Year Old Female: A Case Report

BACKGROUND: Purulent pericarditis is a rare occurrence in the era of modern antibiotics. It is most often caused by organisms such as Staphylococcus aureus, Streptococcus pneumoniae, viridans streptococci, Haemophilus influenzae, and anaerobic bacteria with Streptococcus pyogenes (S. pyogenes) being a possible, though very uncommon etiology. It is usually associated with an underlying infection or compromised immune system. Purulent bacterial pericarditis is a high mortality entity and represents only 1% of the causes of pericarditis, among these only a few cases have been reported of Streptococcus pyogenes pericarditis. This is an extremely rare case of acute purulent bacterial pericarditis caused by S. pyogenes in an immunocompetent adult patient with no underlying chronic medical conditions. CASE PRESENTATION: A 37-year-old healthy female with no known comorbidities came in for chills, dyspnea, chest pain radiating to the upper back aggravated by deep breathing and relieved with leaning forward. She initially presented with unstable vital signs (hypotension and tachycardia). Electrocardiography demonstrated diffuse ST-segment elevation and PR segment depression, while chest Xray and CT scan showed lobar pneumonia. Blood tests showed leukocytosis with neutrophilic predominance indication infection and workup for autoimmune disease was done which was negative. 2D echo showed large pericardial effusion with tamponade physiology. An urgent pericardiocentesis was done with drainage of 350cc nonclotting purulent serous fluid. Cultures grew Streptococcus pyogenes (S. pyogenes) confirming the diagnosis of acute purulent bacterial pericarditis. Management for pericarditis including daily drainage of pericardial effusion, colchicine, ibuprofen was initiated together with antibiotics for the pneumonia and the patient had resolution of the pericardial effusion as documented by repeat 2DED upon follow up.

Abstract 17846: Successful Treatment of Recurrent Pericarditis With Rilonacept in the Setting Of ATRA/ATO Use in Acute Promyelocytic Leukemia

Case Presentation: A 40-year-old female was admitted for a 4-day history of recurrent left-sided pleuritic chest pain. Physical examination was pertinent for tachycardia and presence of a pericardial friction rub. Past medical history included recently diagnosed Acute Promyelocytic Leukemia undergoing active chemotherapy. Complete blood count showed leukopenia. Brain natriuretic peptide was slightly elevated at 241 pg/mL. Electrocardiogram demonstrated sinus tachycardia with diffuse ST-segment elevation and PR-segment depression (Figure 1. A). Echocardiogram showed normal biventricular function with a small posterior and lateral pericardial effusion and small pericardial effusion adjacent to the right ventricle (Figure 1. B). Cardiac magnetic resonance (CMR) imaging showed a moderate circumferential pericardial effusion and increased pericardial signal on T2 STIR imaging and late gadolinium enhancement (LGE) (Figure 1. C, D). Given the constellation of symptoms and findings, the patient was diagnosed with acute pericarditis secondary to differentiation syndrome (DS) suspected to be due to her underlying malignancy and anti-cancer treatments. She was started on aspirin and colchicine. Steroids and rilonacept were later added for incomplete treatment response. On follow-up, she was doing well. Repeat CMR demonstrated mild to moderate pericardial delayed enhancement with no edema and no pericardial effusion (Figure 1. E,F). Discussion: The presentation of DS can vary, and consensus diagnostic criteria are lacking. Cases of myopericarditis with concurrent pericardial effusions have been reported in the setting of patients undergoing chemotherapeutic treatment with differentiating agents. Management is complicated and requires multi-disciplinary care. Our case illustrates that rilonacept may be considered as an alternative to corticosteroids in the treatment of recurrent pericarditis in a patient with a hematologic malignancy.

Prevalence and diagnostic significance of de-novo 12-lead electrocardiogram patterns following covid-19 infection in elite soccer players

Abstract Funding Acknowledgements Type of funding sources: None. Background Considering that myocarditis is implicated in 5-15% of all exercise related sudden cardiac deaths in athletes, following a novel viral pandemic, the identification and risk-stratification of affected athletes remains an important priority. Given its widespread availability, the inclusion of a 12-lead electrocardiogram (ECG) is common to all consensus-based protocols from North America and Europe. However, a single cross-sectional ECG is problematic because several physiological repolarisation changes are also common manifestations in individuals with myopericarditis. Purpose The aim of our study was to report on the prevalence and diagnostic significance of de-novo ECG patterns following COVID-19 infection in a well-defined cohort of elite soccer players in the English, Dutch and Brazilian leagues. Methods In this multicentre observational study, between March 2020–May 2022, we evaluated consecutive athletes with COVID-19 infection. ECGs were reported in accordance with the International recommendations for ECG interpretation in athletes. The following patterns were also considered abnormal if they were not detected on the pre-COVID-19 infection ECG: PR-segment depression, new J-point and ST segment elevation, low QRS voltages, QRS fragmentation, new ST-segment depression, new T-wave inversion, biphasic T-waves and a reduction in the T-wave amplitude by 50% or T-wave flattening. Athletes exhibiting de-novo ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all players (n=30) following COVID-19 infection, despite the absence of cardiac symptoms or de-novo ECG changes. Results 511 soccer players (median age 21-years, IQR:18-26-years) were included, of which 88% were male and 58% white. 17 (3%) athletes demonstrated de-novo ECG changes, which included, a reduction in T-wave amplitude in the inferior and lateral leads (n=5), inferior leads (n=4) and lateral leads (n=4); inferior T-wave inversion (n=7), and ST-segment depression (n=2). 15 (88%) athletes with de-novo ECG changes revealed CMR evidence of inflammatory cardiac sequalae. All athletes who underwent a mandatory CMR irrespective of illness severity or ECG findings, had normal findings. Athletes revealing de-novo ECG changes, had a higher prevalence of cardiac symptoms (71% v 12%; p<0.0001) and longer median symptom duration (5-days, IQR:3-10) compared with athletes without de-novo ECG changes (2-days, IQR:1-3; p<0.001). Among athletes without cardiac symptoms, the additional yield of de-novo ECG changes to detect cardiac inflammation was 17%. Conclusions 3% of athletes demonstrated de-novo ECG changes post COVID-19 infection, of which 88% were diagnosed with inflammatory cardiac sequalae. Most affected athletes exhibited cardiac symptoms; however de-novo ECG changes contributed to a diagnosis of cardiac inflammation in 17% of athletes without cardiac symptoms.

P398 ACUTE PERICARDITIS COMPLICATED BY RAPID DEVELOPMENT OF CONSTRICTION: A CASE REPORT

Abstract A 57–years–old man with no previous cardiovascular history presented with fever, hypotension, dyspnoea at rest and chest pain. The electrocardiogram showed sinus tachycardia, PR–segment depression and diffuse concave–upwards ST–segment elevation. Elevated C–reactive protein and low pro–BNP level were found at lab tests, procalcitonin and troponin were negative. Chest X–ray showed bilateral pleural effusion. Transthoracic echocardiogram (TTE) revealed mild–to–moderate serofibrinous pericardial effusion with initial diastolic collapse of right chambers, suggesting cardiac pre–tamponade. Because of the exiguity of liquid component, pericardiocentesis was not performed, patient was stabilized by fluid–challenge with hypertonic solution. Ibuprofen and colchicine were started. Left thoracentesis was performed removing one liter of fluid overall compatible with transudate. Cytological and microbiological examinations were negative. Despite of initial clinical improvement, the patient showed kidney failure and worsening of lung failure; perianal abscess was detected causing sepsis and requiring surgical drainage and antibiotic therapy with vancomycin and piperacillin/tazobactam. Culture exams were negative. After ibuprofen replacement with indomethacin a repeated TTE showed reduced pericardial effusion, but also respiratory variation in ventricular filling with signs of interventricular dependence. Cardiac magnetic resonance showed thickening and high signal intensity of pericardial layers on T2 weighted imaging and ventricular septal shift on free–breathing cine sequences, suggesting effusive–constrictive pericarditis. Left and right cardiac catheterization demonstrated ventricular “dip and plateau” pattern and ventricular discordance. Considering the lack of clinical improvement on medical therapy, off–bypass pericardiectomy was performed. Incomplete adhesion between the two pericardial layers and thick gelatinous material were found. After surgery patient experienced rapid clinical improvement; cardiac index increased from 1.5 to 3.5 L/min/m2. Effusive–constrictive pericarditis is a rare and dreaded complication of acute pericarditis. Surgery, when appropriated, is crucial for prognosis. In our case initial response to anti–inflammatory therapy with reduced pericardial effusion unmasked constrictive physiology in an effusive–constrictive pericarditis. Clinical management was complicated by sepsis which could have played a role in constriction developing.

Postcardiac injury syndrome caused by radiofrequency catheter ablation of persistent atrial fibrillation: severe pulmonary arterial hypertension with severe tricuspid regurgitation: a rare case report and literature review

BackgroundPostcardiac injury syndrome (PCIS) is an easy-to-miss diagnosis, but it is not an uncommon complication. The phenomenon of echocardiography (ECHO) showing both severe pulmonary arterial hypertension (PAH) and severe tricuspid regurgitation (TR) is indeed rare in PCIS after extensive radiofrequency ablation.Case presentationA 70-year-old male was diagnosed with persistent atrial fibrillation. The patient received radiofrequency catheter ablation due to his atrial fibrillation being refractory to antiarrhythmic drugs. After the anatomical three-dimensional models were created, ablations were performed on the left and right pulmonary veins, roof linear and bottom linear of the left atrium, and the cavo-tricuspid isthmus. The patient was discharged in sinus rhythm (SR). After 3 days, he was admitted to the hospital for gradually worsening dyspnea. Laboratory examination showed a normal leukocyte count with an increased percentage of neutrophils. The erythrocyte sedimentation rate, C-reactive protein concentration, interleukin-6, and N-terminal pro-B-type natriuretic peptide were elevated. ECG exhibited SR, V1-V4 of precordial lead P-wave amplitude which was increased but not prolonged, PR segment depression, and ST-segment elevation. Computed tomography angiography of the pulmonary artery revealed that the lung had scattered high-density flocculent flakes and a small amount of pleural and pericardial effusion. Local pericardial thickening was seen. ECHO showed severe PAH with severe TR. Diuretics and vasodilators did not relieve the symptoms. Tumors, tuberculosis, and immune system diseases were all excluded. Considering the patient’s diagnosis of PCIS, the patient was treated with steroids. The patient recovered on the 19th day post ablation. The patient’s condition was maintained until 2 years of follow-up.ConclusionsThe phenomenon of ECHO showing severe PAH with severe TR is indeed rare in PCIS. Due to the lack of diagnostic criteria, such patients are easily misdiagnosed, leading to a poor prognosis.

What Is the Truth Behind Abnormal ECG Changes?

What Is the Truth Behind Abnormal ECG Changes?

A Case Report of Perimyocarditis as a Rare Complication of Campylobacteriosis

Campylobacter species is one of the most common infections that cause gastroenteritis in developed countries. Although most Campylobacter infections are self-limited, cases can be complicated by extraintestinal presentation, such as myocarditis, pericarditis, or perimyocarditis. We report herein a case of perimyocarditis complicating gastroenteritis in a 24-yearold male. The patient presented with abdominal pain, diarrhea, and dehydration over a couple of days, progressively worsening with substernal chest pain and dyspnea. Troponins were elevated, and ECG showed diffuse concave ST elevation and PR segment depression. Based on the clinical signs and symptoms, the diagnosis of perimyocarditis was made, and he was treated accordingly with a favorable outcome.

A Case Report of Perimyocarditis as a Rare Complication of Campylobacteriosis

Campylobacter species is one of the most common infections that cause gastroenteritis in developed countries. Although most Campylobacter infections are self-limited, cases can be complicated by extraintestinal presentation, such as myocarditis, pericarditis, or perimyocarditis. We report herein a case of perimyocarditis complicating gastroenteritis in a 24-yearold male. The patient presented with abdominal pain, diarrhea, and dehydration over a couple of days, progressively worsening with substernal chest pain and dyspnea. Troponins were elevated, and ECG showed diffuse concave ST elevation and PR segment depression. Based on the clinical signs and symptoms, the diagnosis of perimyocarditis was made, and he was treated accordingly with a favorable outcome.

A case of acute coronary syndrome featuring a forgotten and disguised intruder

An infrequently diagnosed case of atrial infarction which occurred in conjunction with left ventricular myocardial infarction is presented. Atrial infarction was recognised by the presence of PR segment depression in conjunction with premature atrial complexes. Spatial vector analysis of premature atrial complexes, is highlighted as a means to localise atrial infarction.

Frequency of Electrocardiographic Alterations and Pericardial Effusion in Patients With Uncomplicated Malaria

Studies have proposed that malaria may lead to electrocardiographic (ECG) changes and pericardial inflammation. We aimed to investigate the frequency of ECG alterations, determined by ECG and Holter monitoring, and pericardial effusion in patients with malaria infection. We performed a prospective observational study of adult patients with uncomplicated malaria in Amazonas, Brazil. Peripheral blood smears, ECG, and bedside echocardiography were conducted before antimalarial treatment and repeated at follow-up after completed treatment. We evaluated the diagnostic value of PR-segment depression, PR-segment elevation, and Spodick's sign for detecting pericardial effusion. A subset of patients underwent Holter monitoring at baseline. Among 98 cases of uncomplicated malaria (55% men; mean age 40 years; median parasite density 1,774/µl), 75 had Plasmodium vivax, 22 Plasmodium falciparum, and 1 had mixed infection. At baseline, 17% (n=17) had PR-segment depression, 12% (n=12) PR-segment elevation, 3% (n=2) Spodick's sign, and the prevalence of pericardial effusion was 9% (n=9). ECG alterations had sensitivities of 22% to 89% and specificities of 88% to 100% for detecting pericardial effusion at baseline. PR-segment depression had the best accuracy (sensitivity 89%, specificity 90%). Of the 25 patients, 4 patients who did not have pericardial effusion, displayed nonsustained ventricular tachycardia, determined by Holter monitoring (median duration 43 hours). Follow-up examination data were obtained for 71 patients (median 31 days), for whom PR-segment depression, elevation, and pericardial effusion had reduced significantly (p <0.05). In conclusion, our findings suggest that ECG alterations may be useful to detect pericardial effusion in malaria and that these findings decrease after completed antimalarial treatment.

BE CAREFUL, THAT CARDIAC TAMPONADE MAYBE MALIGNANT

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiac tamponade results from the accumulation of pericardial fluid under pressure which causes impaired cardiac filling and hemodynamic compromise. The causes of cardiac tamponade include infection, inflammation, autoimmune diseases, malignancy, drugs, and radiation. Malignancies including lungs, breast, gastrointestinal and hematological may lead to pericardial effusion with or without tamponade. Cardiac tamponade as an initial presentation of malignancy is rare. CASE PRESENTATION: A 63-year-old male presented with altered mental status for 2 weeks, intermittent cough for 6 months, and unintentional weight loss of about 20 lbs. His vitals were blood pressure 125/86, MAP 94, HR 100, and RR 18. He has a medical history of Type 2 diabetes mellitus, hypertension, dyslipidemia, depression, anxiety, tuberculosis (treated in 1970), exposure to radiation during military service, and a family history of multiple malignancies. CT head showed no acute intracranial abnormality. Chest X-ray showed right perihilar pneumonia and the patient was started on antibiotics. CT chest showed multilobar pneumonia, underlying nodularities within the right lung, diffuse sclerotic lesions throughout the skeleton suggestive of metastatic disease, right small pleural effusion, large pericardial effusion. TTE showed moderate to large pericardial effusion with tamponade physiology. He underwent an urgent pericardial window to relieve cardiac tamponade. On analysis, pericardial fluid was malignant. It showed metastatic adenocarcinoma, consistent with lung primary. Immunohistochemical stains show that tumor cells are positive for Ber-EP4, CD15, CK7, and TTF-1. DISCUSSION: There are three routes through which the malignancies involve pericardium – local extension, hematogenous and lymphatic. Pericardial effusion is common in malignancy and when present associated with poor prognosis and can be fatal. Cardiac tamponade is however a rare initial presentation of malignancy. EKG findings in tamponade include low voltage QRS, PR segment depression, electrical alternans, and sinus tachycardia. Diagnosis can be made by echocardiography. CONCLUSIONS: Pericardial effusion with cardiac tamponade may be malignant. Pericardiocentesis in cardiac tamponade has therapeutic efficacy including high diagnostic yield. Pericardial fluid cytology should be examined even if the malignancy is not suspected, especially if the chest x-ray is abnormal. REFERENCE #1: Pericardial diseases in patients with cancer: contemporary prevalence, management, and outcomes. BMJ Volume 106 Issue 8 https://doi.org/10.1136/heartjnl-2019-315852 REFERENCE #2: Cardiac tamponade as the initial presentation of malignancy: is it as rare as previously supposed? BMJ Volume 70 Issue 828 https://doi.org/10.1136/pgmj.70.828.703 REFERENCE #3: Relation of Acute Pericardial Disease to Malignancy. American Journal of Cardiology https://doi.org/10.1016/j.amjcard.2005.01.094 DISCLOSURES: No relevant relationships by Nimesh Adhikari, source=Web Response No relevant relationships by Nouran Eshak, source=Web Response No relevant relationships by Kenneth Iwuji, source=Web Response No relevant relationships by Kenneth Nugent, source=Web Response No relevant relationships by Upama Sharma, source=Web Response No relevant relationships by Anupama Sharma, source=Web Response

The prediction of right atrial pressure using electrocardiogram: a novel approach.

AimsPulmonary hypertension (PH) is a serious disorder that can complicate pulmonary and cardiovascular diseases. Right atrial (RA) pressure is a robust predictor of the pulmonary hypertension severity, which is measured via right heart catheterization. Limited studies have been carried out to assess the association between electrocardiogram data and the RA pressure as a prognostic factor of PH. In this study, the relation between P wave and PR segment changes with RA pressure was evaluated.Methods and resultsIn this study, 94 patients in PH groups of 1, 3, and 4, based on the World Health Organization classification, were entered. RA pressure was measured using the right heart catheterization. PR segment and P wave morphology in leads II and V1 were evaluated in patient's electrocardiogram. The median age of the patients was 35.5 years old in which 64.9% of them were female. The distribution of patients in groups 1, 3, and 4 PH were 77.7%, 5.3%, and 17%, respectively. Among the studied P wave and PR segment changes, PR segment depression in lead II and pulmonary P wave in lead V1 had significant relation with the RA pressure (P‐value <0.001). The sensitivity, specificity, and negative predictive values of PR segment depression for detection of patients with high RA pressure (RA pressure > 14 mmHg) were 80%, 84%, and 94%. The specificity and negative predictive values of pulmonary P wave in lead V1 were determined 89% and 88%.ConclusionsIt was found that the PR segment depression in lead II and pulmonary P wave in lead V1 associate with the RA pressure in patients with precapillary PH. PR segment depression had useful sensitivity, specificity, and negative predictive values, and the pulmonary P wave in lead V1 had acceptable specificity and negative predictive values for detection of patients with high RA pressure. Therefore, the electrocardiogram can be used as a screening tool for determination of pulmonary hypertension severity.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

A Suspected COVID-19-associated Myocarditis Case Mimicking Life-threatening STEMI: a Shark Fin Appearance

Some cases of myocarditis have been reported associated to Covid-19. The presence of proinflammatory response from immune cells suggested occurs by binding to membrane protein ACE-2 leading to myocardial damage. Our hospital got a refferal from a non-PCI-capable hospital with a 51-years-old woman chest pain and progressive heavy breath with history of fever two days ago. She was diagnosed with anterior STEMI and cardiogenic shock on vassopressors. Her electrocardiogram showed shark fin appearance suggesting life-threatening STEMI. Her rapid test for covid-19 are non-reactive for both IgM and IgG. Her NCCT-thorax showed ground glass opacity in both lungs. Her laboratories finding showed elevated inflammatory markers and elevated cardiac biomarker. We took her naso-oro-pharingeal swab in the same day and process her with emergency PCI. Surprisingly, her angiography showed normal coronary artery without any significant stenosis. From There was no SARS-CoV-2 detected. In myocarditis, patient can mimick the same symptoms as STEMI such as chest pain and heavy breath with elevated cardiac biomarker, but the electrocardiogram usually shows widespread concave ST-elevation with PR-segment depression. Shark fin appearance is usually seen in life-threatening STEMI. In our patient, the NCCT-thorax showed GGO suggested Covid-19 involvement. But, the first swab was negative for SARS-CoV-2. Unfortunately, the patient was discharged without doctor’s consent, so we can not process the second swab and echocardiography to evaluate the function of myocardium. We still can not confirmed this case if it is true myocarditis-associated covid-19 and how was the involvement of the myocardium creating a shark fin mimicking life-threatening STEMI.

Purulent pericarditis-induced intracardiac perforation and infective endocarditis due to Parvimonas micra: a case report.

BackgroundPurulent pericarditis, a rare disease with a high associated mortality rate in patients without adequate treatment, can cause serious complications, such as perforation of the surrounding tissue and organs. Parvimonas micra is a very rare cause of purulent pericarditis.Case summaryA 70-year-old male patient presented to our emergency room with chest pain of 10 days’ duration. An electrocardiogram showed ST-segment elevation and PR-segment depression on multiple leads. A transthoracic echocardiogram showed normal left ventricular function and a large amount of pericardial effusion. Acute pericarditis was diagnosed, and anti-inflammatory drug therapy was initiated. Due to the lack of improvement in the symptoms, pericardiocentesis was performed on Day 8 and revealed about 800 cc of the bloody fluid. Parvimonas micra was detected in a culture of the pericardial effusion and blood. Although intravenous antibiotic therapy was initiated for purulent pericarditis, his fever persisted. Computed tomography of the chest performed on Day 14 showed an abscess cavity in the pericardial space around the right atrium (RA). Furthermore, transoesophageal echocardiography revealed vegetation in the RA. Emergency surgery confirmed the presence of vegetation and minor perforation of the RA with communication to the abscess cavity. After surgical therapy, the patient clinically improved and was discharged on Day 51.DiscussionIn cases of acute pericarditis, purulent pericarditis should be considered if clinical improvement is not observed after initial treatment with anti-inflammatory drugs. Once the diagnosis of purulent pericarditis is made, aggressive source control is necessary for improved clinical outcomes.

PR depression with multilead ST elevation and ST depression in aVR by left circumflex artery occlusion: How to differentiate from acute pericarditis

PR‐segment depression with multilead ST‐segment elevation and ST‐segment depression in lead aVR are classic ECG manifestation of acute pericarditis. We present a patient, where the etiology of these ECG features was acute ST‐elevation myocardial infarction due to left circumflex artery occlusion. To avoid misdiagnosis, unnecessary examinations, and inappropriate therapeutic decisions, the possibility of ST‐segment elevation myocardial infarction should be kept in mind even when ECG changes typical for pericarditis are encountered in chest pain patients. Findings of QRS widening and QT interval shortening in leads with ST‐segment elevation could help to differentiate acute ST‐segment elevation myocardial infarction from acute pericarditis.

Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review

BackgroundAcute myocarditis represents a challenging diagnosis as there is no pathognomonic clinical presentation. In patients with myocarditis, electrocardiogram (ECG) can display a variety of non‐specific abnormalities. Nevertheless, ECG is widely used as an initial screening tool for myocarditis.MethodsWe researched all possible ECG alterations during acute myocarditis evaluating prevalence, physiopathology, correlation with clinical presentation patterns, role in differential diagnosis, and prognostic yield.ResultsThe most common ECG abnormality in myocarditis is sinus tachycardia associated with nonspecific ST/T‐wave changes. The presence of PR segment depression both in precordial and limb leads, a PR segment depression in leads with ST segment elevation, a PR segment elevation in aVR lead or a ST elevation with pericarditis pattern favor generally diagnosis of perimyocarditis rather than myocardial infarction. In patients with acute myocarditis, features associated with a poorer prognosis are: pathological Q wave, wide QRS complex, QRS/T angle ≥ 100°, prolonged QT interval, high‐degree atrioventricular block and malignant ventricular tachyarrhythmia. On the contrary, ST elevation with a typical early repolarization pattern is associated with a better prognosis.ConclusionsECG alterations in acute myocarditis could be very useful in clinical practice for a patient‐tailored approach in order to decide appropriate therapy, length of hospitalization, and frequency of followup.

PR-segment depression during cryoballoon ablation of atrial fibrillation: a case report.

PR-segment depression during cryoballoon ablation of atrial fibrillation: a case report.

PR depression with multi‑lead ST elevation and ST depression in aVR: Is it always acute pericarditis?

The classic electrocardiographic (ECG) manifestation of stage I of acute pericarditis is diffuse ST elevation and PR depression with ST depression in lead aVR. One of the most common conditions, that is often confused with acute pericarditis, is the benign diffuse ST elevation, termed “early repolarization with ST elevation” (ERSTE). ERSTE often presents with diffuse ST elevation in the inferior and anterolateral leads, with or without terminal QRS notching or slurring. As ERSTE often presents with ST elevation in leads I and II, frequently there is concomitant ST depression in lead aVR, similar to the acute pericarditis ECG pattern. Moreover, PR depression in the inferior leads and/or PR elevation in lead aVR is often seen. Here we describe four patients with ERSTE, all had ST elevation in II with either ST elevation or isoelectric ST in lead I and concomitant ST depression in aVR. Two also had PR depression in the inferior leads. None of the patients had clinical symptoms or signs of acute pericarditis. In conclusion, diffuse ST elevation in the inferolateral leads associated with ST depression in aVR and even with PR segment depression is commonly found in ERSTE and should not be considered as pathognomonic of only acute pericarditis.