Epistenocardiac pericarditis can be an electrocardiographic challenge!
LOVELYCHHABRA, MD, Cardiology Fellow,
, ,
Other Contributors:
November 23, 2015
We enjoyed the image challenge published by Wu et al which
illustrates a case of contained left ventricular rupture [1]. In the
explanation, authors have excluded pericarditis based on the absence of
fever and characteristic pericarditis ECG findings. We would like to
emphasize that early post-infarction pericarditis ("epistenocardiac") is
notorious to cause atypical ECG changes which are often territorial to the
infarct area [2-5]. One of our previous studies demonstrated that only
3.2% patients with epistenocardiac pericarditis present with classical
Stage-I pericarditic ECG changes [4]. Pericarditis in the presented case
should be correctly ruled out by the absence of a pericardial rub and the
presence of significant reciprocal ST-depressions in III and aVF on the
third ECG-tracing. Authors also point out that the key to the diagnosis
for left ventricular free wall rupture (LVFWR) is the presence of
pericardial effusion. In our opinion, the absence of pericardial effusion
has a very high negative predictive value for LVFWR, however the presence
of it (even hemorrhagic effusion) does not confirm the diagnosis as an
effusion may often accompany an 'effusive epistenocardiac pericarditis'
[2]. The hallmark to the echocardiographic diagnosis of LVFWR is the
actual visualization of wall-rupture and/or the classical color-doppler
findings with or without the use of an echo contrast [2].
References:
1.Wu H, Qian J, Ge J. Recurrent ST-segment elevation in infarct-associated
leads. Heart. 2014 Jul 29. pii: heartjnl-2014-306289. doi:
10.1136/heartjnl-2014-306289. (PMID: 25073887).
2.Spodick DH: The Pericardium: A Comprehensive Textbook, Marcel Dekker,
New York 1997. pp: 334-367.
3.Bruce MA, Spodick DH. Atypical electrocardiogram in acute pericarditis:
characteristics and prevalence. J Electrocardiol. 1980;13(1):61-66.
4.Krainin FM, Flessas AP, Spodick DH. Infarction-associated pericarditis.
Rarity of diagnostic electrocardiogram. N Engl J Med. 1984;311(19):1211-
1214.
5.Chhabra L, Chaubey VK, Spodick DH. Recurrent myocardial infarction or
Epistenocardiac pericarditis: how can surface ECG be useful in clinical
decision making? Hellenic J Cardiol. 2014. In Press.
We enjoyed the image challenge published by Wu et al which illustrates a case of contained left ventricular rupture [1]. In the explanation, authors have excluded pericarditis based on the absence of fever and characteristic pericarditis ECG findings. We would like to emphasize that early post-infarction pericarditis ("epistenocardiac") is notorious to cause atypical ECG changes which are often territorial to the infarct area [2-5]. One of our previous studies demonstrated that only 3.2% patients with epistenocardiac pericarditis present with classical Stage-I pericarditic ECG changes [4]. Pericarditis in the presented case should be correctly ruled out by the absence of a pericardial rub and the presence of significant reciprocal ST-depressions in III and aVF on the third ECG-tracing. Authors also point out that the key to the diagnosis for left ventricular free wall rupture (LVFWR) is the presence of pericardial effusion. In our opinion, the absence of pericardial effusion has a very high negative predictive value for LVFWR, however the presence of it (even hemorrhagic effusion) does not confirm the diagnosis as an effusion may often accompany an 'effusive epistenocardiac pericarditis' [2]. The hallmark to the echocardiographic diagnosis of LVFWR is the actual visualization of wall-rupture and/or the classical color-doppler findings with or without the use of an echo contrast [2].
References: 1.Wu H, Qian J, Ge J. Recurrent ST-segment elevation in infarct-associated leads. Heart. 2014 Jul 29. pii: heartjnl-2014-306289. doi: 10.1136/heartjnl-2014-306289. (PMID: 25073887). 2.Spodick DH: The Pericardium: A Comprehensive Textbook, Marcel Dekker, New York 1997. pp: 334-367. 3.Bruce MA, Spodick DH. Atypical electrocardiogram in acute pericarditis: characteristics and prevalence. J Electrocardiol. 1980;13(1):61-66. 4.Krainin FM, Flessas AP, Spodick DH. Infarction-associated pericarditis. Rarity of diagnostic electrocardiogram. N Engl J Med. 1984;311(19):1211- 1214. 5.Chhabra L, Chaubey VK, Spodick DH. Recurrent myocardial infarction or Epistenocardiac pericarditis: how can surface ECG be useful in clinical decision making? Hellenic J Cardiol. 2014. In Press.
Conflict of Interest:
None declared