Lau, CP

Wan, SH

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Title ECG Round: Acute pericarditisAuthor(s) Lau, CP; Wan, SHCitation Hong Kong Practitioner, 1997, v. 19 n. 10, p. 546-548Issued Date 1997URL http://hdl.handle.net/10722/53419Rights Creative Commons: Attribution 3.0 Hong Kong LicenseECG ROUNDClinical History:A 28-year-old gentleman attended the Accident and Emergency Department wi th one day history of sharp,retrosternal chest pain. The following ECG strip was obtained.Figure 1: Vent, rate 62 BPM' PR interval 136 msI QRS duration 100 msi'QT/QTc 392/338 msP-R-T axes -16 72 46What was the diagnosis?A. Acute PericarditisB, Acute Myocardial Infarction (extensive)C. Unstable AnginaD. Early Repolarization (Normal Variant)This ECG Round was prepared by: Dr. S.H. Wan and Prof. C.P. LauAddress for correspondence: Dr Siu-hong Wan, Cardiology, Department of Medicine & Geriatrics, Tuen Mun Hospital, New Territories. Hong Kong.546Hong Kong Practitioner 19 (10) October 1997ECG ROUNDAnswer: A. Acute PericarditisThe electrocardiogram showed widespread andgeneralised ST segment elevations with a concave upwardappearance. The ST segment elevations involved all limband chest leads except lead aVR which showed areciprocal depression. There were no significant changesin the QRS complexes. This electrocardiogram is typicalof acute pericarditis.In acute myocardial infarction, there are usually moreleads with reciprocal ST segment depressions, Q waves aswell as loss of the a m p l i t u d e of the R waves. Serialelectrocardiograms are very useful in the d i f fe ren t ia ld i agnos i s . For acute p e r i c a r d i t i s , the ST segmentelevations usua l ly normalise in a few days t ime and Twave i n v e r s i o n s then deve lop . Whereas in acu temyocardial infarction, T wave inversions occur in a matterof hours before the normalisation of the ST segments. Inunstable angina, ST depressions wi th or without T wavechanges occur. In early repolarization, the widespread STsegment elevations usually involve the chest leads and theST/T ratio is less than 0.25.'The chest pain in acute pericarditis is typically sharpin nature, locates precordially and radiates to the back andthe trapezius ridge. The pain is often pleuritic in naturewhich is aggravated by breathing, coughing and relievedby sitting up and leaning forward. The patient may haveprodromal symptoms of a viral infection 10-14 days beforethe onset of the chest pain. Clinical signs include fever,tachycardia and pericardial friction rub ( typical ly highpitched and scratchy in nature).Question 2: What investigations would you do?A. Chest X-rayB. Complete blood picture (CBP) and blood cultureC. EchocardiogramD. Viral titre and autoimmune markersAnswer: ALL of the aboveThe underlying causes for pericarditis include viralinfections (e.g. Coxackie viruses A or B, echovirus, herpess i m p l e x or a d e n o v i r u s ) , bac ter ia l i n f e c t i o n s (e.g.tuberculosis), neoplasm (e.g. carcinoma of lung or breast),co l l agen v a s c u l a r diseases (e.g. sys t emic l u p u serythematosus or rheumatoid arthritis), hypothyroidism,post cardiac injury (post myocardial infarction or postcardiac procedures) and drugs (e.g. procainamide,hydralazine). The investigations therefore should includecomple te blood p i c t u r e , blood c u l t u r e , v i r a l t i t re,antinuclear factor, rheumatoid factor, thyroid function test,tuberculin skin test, chest x-ray, serial electrocardiogramsand echocardiogram.Question 3: What treatment would you give?A. ThrombolyticsB. AspirinC. NitroglycerinD. B-blockerAnswer: B. AspirinAspirin 2-4 g per day (e.g. 600-900mg qid) is therecommended treatment of acute pericarditis. If this failsto control the symptoms, other non-steroidal an t i -inflammatory drugs (e.g. indomethacin 25-75 mg qid) orsteroid can be started.Around 80% of acute pericarditis are considered tobe idiopathic, presumably due lo viral infeclions.2 Themost important complication of acute pericarditis ispe r i ca rd i a l e f fu s ion . I f the pe r i ca rd ia l e f f u s i o naccumulales in a relatively short period of time or asufficiently large volume of fluid accumulates slowly,cardiac tamponade may develop. Echocardiogram isinvaluable for the diagnosis which shows the pericardialeffusion as well as the typical diastolic collapse of ther ight ventr icle . Drainage of the per icardial f lu id547ECG RoundECG ROUND(pericardiocentesis) usually by the subxiphoid approachunder ultrasound or fluoroscopic guidance is necessary.Most patients with acute pericarditis wil l recoverwithout any complications. However, some of them maydevelop recurrence which requires further courses of non-steroidal or steroidal anti-inflammatory drugs. Occasion-ally, azathioprine and colchicine may be used.3'4 •ReferencesHarrison's Principles of Internal Medicine 13th Edition. 1994;1:1094-1098.Ricardo Z, Manuel A, Francisco T, et al. Incidence of Specific Etiologyand Role of Methods for Specific Etiologic Diagnosis of Primary AcutePericarditis. Am J Cardiol 1995;75:378-382.Guindo J, et al. Recurrent Pericarditis: Relief with colchicine. Circulation1990;82:1117.Marcolongo R, Russo R, Laveder F, et al. Immunosuppressive therapyprevents recurrent pericarditis. J Am Coll Cardiol. 1995;26:1276-1279.HKCFP AWARD FOR THE BESTThe Research Committee of the Hong Kong College of Family Physicians has set up a Prize Award to theBest Research of the Year in 1997. All members and fellows of the College are invited to participate and submittheir research papers to the Research Committee for selection. The Prize would be presented at the ConfermentCeremony in 1998. : ' " . ' . ' , ' ' ' :.^'<:-i-v?vi|^,- •;. Entry and assessment criteria are listed below: -'''.<'.. '• •'••. 'i;ftS?!t'*Kg£:i^: '3-- ''&••':•:'•) "•- >;« •'•>•;•' ;.t '-:;'-;.:-^i?v---'^C-:w/®.Entry Criteria:1. The principal author has to be a member or fellow,; : 2. The research must be original work of the author(s). "":S'V;:o5l;*-iSCfe^lV ^v, :". '.--,' >,.''.;£''%•.'"•"' 3. The research should be done in Hong Kong. - : ' ;' ^ ' ;' ""' vl!f^"-'^ :- 'f '*•* t|> "" - 'r.::;:';*;? = "'""' "'•'• '•'''' *'- '.yt"l•">.:•': 4. The research must have been completed. ' - .'•-•'^'^SK'f^IJi^5. The paper should be presented under the standard headings of Abstract, Introduction, Methodology,Results, Discussion: and Conclusion. References should be listed in full at the end in Harvard orVancouver format, , " . ' ' . ' • ' ' • ' ' ' • ' ' ' . . ' • ' •• • • ' - C^iZV^§:"'is..;;jISW:-???':5fcH;':-t .• • . •-•• . ,;:!«*:fe v-..•'. Assessment Criteria: '~:,.'.J-\'.. C,~.^-v. :: •••i^^':&ff^1. How relevant is the topic a2.3.4.5.6.7.How well designed is the methodology? ; 'How well are the results presented and analysed?How appropriate is the discussion and conclusion?How useful are the results for patient care in GeneralHow much effort is required?; Each research will bewill attract different:^""'DEADLINE OF SUBMISSION: 3lst548

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