Blog, Outcomes and Pericarditis - Cardiovascular Update

Healthy 45-year-old with chest pain: early repolarization, pericarditis or injury?

Dr. Smith's ECG Blog

SEPTEMBER 25, 2024

The computer interpretation was “ST elevation, consider early repolarization, pericarditis or injury.” The final cardiology interpretation confirmed the computer interpretation of “ST elevation, consider early repolarization, pericarditis or injury”. A healthy 45-year-old female presented with chest pain, with normal vitals.

Chest Pain

Chest Pain Pericarditis SCAD STEMI

You Diagnose Pericarditis at your Peril (at the Patient's Peril!)

Dr. Smith's ECG Blog

JUNE 20, 2018

Clinician and EKG machine read of acute pericarditis. While it is true that inferior MI has ST depression in aVL 99% of the time (Bischof and Smith), and that inferolateral ST elevation is the most common distribution for pericarditis, the ST elevation in V3 has "terminal QRS distortion (TQRSD)," (diagnostic of LAD occlusion).

Pericarditis

Pericarditis Chest Pain Blog Ultrasound

Watch what happens when "pericarditis" and morphine cloud your judgment

Dr. Smith's ECG Blog

JULY 3, 2018

06:44 - T-waves in V2 are smaller now - Overall resolution of prior findings (which qualifies as a dynamic change) The initial note by the cardiologist states that the presentation is more consistent with pericarditis. Remember, pericarditis is the thing you say and write down when youre actively trying to miss an OMI.

Pericarditis

Pericarditis Chest Pain Stents Stent

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Will this case be flagged for Quality Improvement in the STEMI/NSTEMI Paradigm?

Dr. Smith's ECG Blog

MARCH 27, 2025

Below is the first ECG, signed off by the over-reading cardiologist agreeing with the computer interpretation: ST elevation, consider early repolarization, pericarditis, or injury. Theres ST elevation in V3-4 which meets STEMI criteria, which could be present in either early repolarization, pericarditis or injury. What do you think?

STEMI

STEMI Chest Pain Pericarditis Ischemia

A man in his late 30s with acute chest pain and ST elevation

Dr. Smith's ECG Blog

MAY 16, 2023

There is a reasonable chance of pericarditis in this case, or this could be a baseline." Other outcome information is not available. Sadly, I did not receive enough information to adjudicate whether this patient has pericarditis or not. But I would cath unless there is some clear clinical feature that points to pericarditis.

Chest Pain

Chest Pain Pericarditis Tachycardia STEMI

Quiz post: 2 similar patients with similar ECGs. Which, if any, or both, are OMI? Will you outperform the Queen of Hearts?

Dr. Smith's ECG Blog

NOVEMBER 29, 2023

Queen of hearts interpretations: Patient 1, ECG1: Patient 2, ECG1: Patient 1 Clinical Course and Outcome: The EM physician did not see that the S wave voltage has been truncated and squared off at 10 mm, thereby greatly limiting the assessment of proportionality. He diagnosed anterior "STEMI" and activated the cath lab. But he did well.

STEMI

STEMI Chest Pain Blog Pericarditis

Three prehospital ECGs in patients with chest pain

Dr. Smith's ECG Blog

AUGUST 6, 2024

These latter findings are typical of pericarditis, but pericarditis never has reciprocal ST depression. Usually with pericarditis and myocarditis — hyperacute T waves (HATW) are not present. S mith : there is STE in lead III and reciprocal STD in aVL. This is OMI until proven otherwise.

Chest Pain

Chest Pain Ischemia Pericarditis Tachycardia

A teenager involved in a motor vehicle collision with abnormal ECG

Dr. Smith's ECG Blog

FEBRUARY 6, 2024

ECG of pneumopericardium and probable myocardial contusion shows typical pericarditis Male in 30's, 2 days after Motor Vehicle Collsion, complains of Chest Pain and Dyspnea Head On Motor Vehicle Collision. Atrial fibrillation is also a predictor of worse outcomes in this case (Alborzi). ST depression. Myocardial Contusion?

Tachycardia

Tachycardia Dysrhythmia Atrial Fibrillation Bradycardia

What is lurking underneath this new right bundle branch block?

Dr. Smith's ECG Blog

NOVEMBER 25, 2017

Peak troponin, echocardiographic findings, and long term outcome are unknown. On day 3 of hospitalization she underwent coronary angiography, revealing a 95% lesion in the mid-LAD which was stented. One can say with full confidence that is was completely occluded at the time of the presentation ECG. Learning Points: 1.

Chest Pain

Chest Pain Pericarditis Embolism Stents

Quiz post: do either or both of these patients have high lateral OMI / South African flag sign?

Dr. Smith's ECG Blog

JANUARY 12, 2023

Here is the South African Flag sign ( Figure by Ken Grauer — with the original 12-lead from Patient 1 attached below — See his Comment from the April 8, 2022 post in Dr. Smith's ECG Blog for more on this sign ). Patient 1: A woman in her 60s presented with 10 days of intermittent chest tightness. What is the South African Flag Sign?

Chest Pain

Chest Pain STEMI Blog Stenosis

ECG Blog #448 — A Young Man with Chest Pain.

Ken Grauer, MD

SEPTEMBER 21, 2024

Pericarditis is rare — but myocarditis is not , so especially in this age group — more information is needed to quickly determine if this could be an acute MI, myocarditis, or none of the above. To quote Dr. Stephen Smith: "The worst risk factor for a bad outcome in acute MI is young age." Figure-1: The initial ECG in today's case. (

Chest Pain

Chest Pain Blog Thrombosis Tachycardia

Occlusion myocardial infarction is a clinical diagnosis

Dr. Smith's ECG Blog

DECEMBER 11, 2023

Recall from this post referencing this study that "reciprocal STD in aVL is highly sensitive for inferior OMI (far better than STEMI criteria) and excludes pericarditis, but is not specific for OMI." St depression in lead AVL differentiates inferior st-elevation myocardial infarction from pericarditis. link] Bischof, J. Worrall, C.,

Myocardial Infarction

Myocardial Infarction Chest Pain STEMI Blood Pressure

Subacute AnteroSeptal STEMI, With Persistent ST elevation and Upright T-waves

Dr. Smith's ECG Blog

JULY 18, 2014

such Q-waves are associated with larger MI and worse outcomes (2. When there is MI extending all the way to the epicardium (transmural), that infarcted epicardium is often inflamed (postinfarction regional pericarditis, or PIRP). What complication is the patient with post-infarction regional pericarditis at risk for?

STEMI

STEMI Pericarditis Myocardial Infarction Cardiogenic Shock

Large Transmural STEMI with Myocardial "Rupture" of Ventricular Septum

Dr. Smith's ECG Blog

JULY 7, 2013

and these are associated with larger MI and worse outcomes (2. When there is MI extending all the way to the epicardium (transmural), that infarcted epicardium is often inflamed (postinfarction regional pericarditis, or PIRP). Although the patient has had pain for 4 days, could the artery have fully occluded only within hours?

STEMI

STEMI Myocardial Infarction Pericarditis Ultrasound

Two patients with chest pain, with QRS obscured: which was STEMI positive, and which had Occlusion MI?

Dr. Smith's ECG Blog

JANUARY 17, 2024

The initial computer and final cardiology interpretation was a differential: “ST elevation, consider early repolarization, pericarditis, or injury.” But STEMI criteria ignore all this and look at ST segments in isolation. Based on STEMI criteria and unhelpful computer interpretation, the patient was rushed to the cath lab.

Chest Pain

Chest Pain STEMI Myocardial Infarction Blog

Initial Reperfusion T-waves, Followed by Pseudonormalization. Diagnosis?

Dr. Smith's ECG Blog

MARCH 11, 2016

Post-infarction Regional Pericarditis (PIRP) PIRP happens when MI is transmural, all the way from subendocardium to subepicardium, thus leading to inflammation of the subepicardium (next to the pericardium). MYOCARDIAL RUPTURE AND POSTINFARCTION REGIONAL PERICARDITIS KEY POINTS · Myocardial rupture occurs in 1 to 1.5% Re-occlusion 2.

Myocardial Infarction

Myocardial Infarction Pericarditis STEMI Angina

Should we activate the cath lab? A Quiz on 5 Cases.

Dr. Smith's ECG Blog

OCTOBER 8, 2023

ECG#1 ECG#2 ECG#3 ECG#4 ECG#5 See outcomes of all 5 below, with the Queen of Hearts AI Bot interpretation. All of the patients presented with chest pain , and they are all in triage. Which, if any, of these patients has OMI, with myocardium at risk and need for emergent PCI? YOU TOO CAN HAVE THE PM Cardio AI BOT!!

Ischemia

Ischemia Chest Pain Cardiogenic Shock Cardiac Arrest

Inferior ST Elevation: what is the Diagnosis?

Dr. Smith's ECG Blog

OCTOBER 5, 2011

T-wave to ST ratio is greater than 4 in lead V6, making pericarditis unlikely (also there were no symptoms of pericarditis). Long-term outcome associated with early repolarization on electrocardiography. There is ST elevation diffusely: 2 mm in V2, 3.5 mm in V3, 2.5 mm in V4, 1.5 mm in V5, and 1 mm in V6, 1.5

Chest Pain

Chest Pain STEMI Pericarditis Cardiac Arrest

Cardiologist declines taking patient to the cath lab. Patient dies.

Dr. Smith's ECG Blog

OCTOBER 11, 2020

As always, takotsubo cardiomyopathy and focal pericarditis can mimic OMI, but takotsubo almost never mimics posterior MI, and both are diagnoses of exclusion after a negative cath. Like other cases on this blog who died before cath was done, I cannot prove that this patient had OMI. I do not accept the transfer." "It Were they right?

Chest Pain

Chest Pain STEMI Blog Tachycardia

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Dr. Smith's ECG Blog

JANUARY 9, 2023

Smith Major Learning Point: The worst risk factor for a bad outcome in OMI is young age because cardiologists cannot believe that a young person can have an OMI. Pericarditis? He was readmitted a few weeks later for a heart failure exacerbation, diuresed, and discharged again. This gets drilled into them.

Chest Pain

Chest Pain Aneurysm STEMI Thrombosis

Hyperacute T wave or not: do any of these 4 ‘STEMI’ ECGs have Occlusion MI?

Dr. Smith's ECG Blog

NOVEMBER 30, 2024

In addition, ischemic STD in aVL is highly sensitive for inferior OMI, and excludes pericarditis. for both pericarditis and normal variant, the vector results in more STE in II than III, and absence of STD in aVL. It means that, if there is STD in aVL, then it is almost certainly not pericarditis (but could be myocarditis).

STEMI

STEMI Chest Pain Pericarditis Coronary Artery Disease

Chest pain followed by 6 days of increasing dyspnea -- what happened?

Dr. Smith's ECG Blog

FEBRUARY 26, 2025

The exception is with postinfarction pericarditis , in which a completed transmural infarct results in inflammation of the subepicardial myocardium and STE in the distribution of the infarct, and which results in increased STE and large upright T-waves. These findings together are more commonly seen with pericarditis.

Chest Pain

Chest Pain Pericarditis Myocardial Infarction Dementia

Healthy 45-year-old with chest pain: early repolarization, pericarditis or injury?

You Diagnose Pericarditis at your Peril (at the Patient's Peril!)

Watch what happens when "pericarditis" and morphine cloud your judgment

Webinars

Will this case be flagged for Quality Improvement in the STEMI/NSTEMI Paradigm?

A man in his late 30s with acute chest pain and ST elevation

Quiz post: 2 similar patients with similar ECGs. Which, if any, or both, are OMI? Will you outperform the Queen of Hearts?

Three prehospital ECGs in patients with chest pain

A teenager involved in a motor vehicle collision with abnormal ECG

What is lurking underneath this new right bundle branch block?

Quiz post: do either or both of these patients have high lateral OMI / South African flag sign?

ECG Blog #448 — A Young Man with Chest Pain.

Occlusion myocardial infarction is a clinical diagnosis

Subacute AnteroSeptal STEMI, With Persistent ST elevation and Upright T-waves

Large Transmural STEMI with Myocardial "Rupture" of Ventricular Septum

Two patients with chest pain, with QRS obscured: which was STEMI positive, and which had Occlusion MI?

Initial Reperfusion T-waves, Followed by Pseudonormalization. Diagnosis?

Should we activate the cath lab? A Quiz on 5 Cases.

Inferior ST Elevation: what is the Diagnosis?

Cardiologist declines taking patient to the cath lab. Patient dies.

A teenager with chest pain, a troponin below the limit of detection, and "benign early repolarization"

Hyperacute T wave or not: do any of these 4 ‘STEMI’ ECGs have Occlusion MI?

Chest pain followed by 6 days of increasing dyspnea -- what happened?

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