EKGenie March 2018

Case:

63 yo female with PMH of HTN, HLD presets with pleuritic chest pain for 4 days.Pain is substernal, radiates to R shoulder and R neck, worse with deep inspiration and laying backward. 

Vital Signs: BP 158/71, HR 83, RR 17, Temp 98.2, O2 sat 98% RA

Exam: regular rate and rhythm, no murmur, no rub 

EKG1.jpg

+ Rate

80

+ Rhythm

Sinus, regular

+ Intervals

WNL

+ Pathology

o Diffuse ST Elevation o Look at aVR – you see ST depression and PR elevation

+ Diagnosis

Pericarditis

Key features include:

  1. Diffuse ST elevation with PR depression
  2. PR elevation and ST depression in aVR
  3. Concave ST segments
  4. ST elevation in lead II > lead III

+ Why is this important?

As an EM physician we have to know the difference between pericarditis and STEMI. This can sometimes be very challenging. Below is a table comparing the two. We also highly recommend checking out the life in the fast lane link below for Amal Mattu's lecture on this!

+ What should be your next step in mangement

Once you've been the BOSS EM Doc that we know you are and determined that this is NOT a STEMI and is pericarditis, treatment includes: • Aspirin 650-975 mg TID-QID for 1-2 weeks • NSAIDs o Ibuprofen 400-800 mg TID for 1-2 weeks o Indomethacin 50 mg TID for 1-2 weeks • Colchicine 0.5 or 0.6mg BID up to 3 months o in studies comparing colchicine + either aspirin or NSAID vs aspirin or NSAID alone, pts who received colchicine had lower rates of recurrence, quicker alleviation of symptoms and decreased hospital stay. o Contraindications to colchicine use = pericarditis 2/2 to malignancy, TB or bacterial infection/ pregnancy/ significant liver of kidney disease • Steroids – only use in pts who cannot tolerate NSAIDs + colchicine tx • PPI – this is a stylistic point! Remember you're giving your patients high dose NSAIDs or aspirin plus colchicine, or steroids, all of which can cause GI upset. To minimize the GI side effects don’t forget about a PPI

+ Additional resources

• Great LITFL segment on pericarditis vs STEMI http://lifeinthefastlane.com/heres-the-rub-stemi-vs-pericarditis/http://lifeinthefastlane.com/ecg-library/basics/pericarditis/ • L. Lilly, Treatment of Acute and Recurrent Idiopathic pericarditis http://circ.ahajournals.org/content/127/16/1723.full.pdf+html#sec-3 • M. Imazio et al. A Randomized trial of colchicine for acute pericarditis http://www.nejm.org/doi/full/10.1056/NEJMoa1208536 • REBEL EM colchicine for acute pericarditis http://rebelem.com/colchicine-treatment-pericarditis/

Dr Smith’s EKG Blog: http://hqmeded-ecg.blogspot.com.au/search/label/Wellens%27%20syndrome

REBEL EM: http://rebelem.com/r-e-b-e-l-ecg-week-wellens-syndrome-stemi/

Amal Mattu: Wellens? Maybe? https://www.youtube.com/watch?v=5UfPqNL2DaY