Acute pericarditis is common but illusive, often mimicking acute coronary syndrome in its clinical and electrocardiographic presentation. Regional pericarditis, though rare, presents further challenge with a paucity of published diagnostic criteria. We present a case of postoperative regional pericarditis and discuss helpful electrocardiographic findings. A 66-year-old male with history of open drainage of a liver abscess presented with abdominal pain and tenderness. CT of the abdomen was concerning for pneumatosis intestinalis of the distal descending colon. He underwent lysis of liver adhesions; exploration revealed only severe colonic impaction, for which he had manual disimpaction and peritoneal irrigation. Postoperatively, he developed sharp chest pain. Electrocardiogram revealed inferior ST elevation. Echocardiogram revealed normal left and right ventricular dimensions and systolic function without wall motion abnormalities. Emergent coronary angiography did not identify a culprit lesion, and left ventriculogram showed normal systolic function without wall motion abnormalities. He received no intervention, and the diagnosis of regional pericarditis was entertained. His cardiac troponin was 0.04 ng/dL and remained unchanged, with resolution of the ECG abnormalities in the following morning. Review of his preangiography ECG revealed PR depression, downsloping baseline between QRS complexes, and reciprocal changes in the anterior leads, suggestive of regional pericarditis.
Prompt evaluation of an electrocardiogram (ECG) remains the basis for the initial workup and early implementation of life-saving therapy in patients presenting with chest pain suggestive of acute coronary syndrome (ACS). Vigilance, however, is recommended in the interpretation of the ECG, paying attention to atypical clinical or electrocardiographic features which may point at an alternative diagnosis, mandating further diagnostic studies and different management. We present a case of regional pericarditis with electrocardiographic features mimicking an inferior myocardial infarction, prompting early cardiac catheterization. Subtle ECG findings, however, can serve as clues to the presence of pericarditis rather than myocardial ischemia. Review of pertinent literature is provided.
A 66-year-old white male with known hypertension and diabetes mellitus and prior open drainage of a liver abscess presented to our emergency department with abdominal pain and tenderness. The patient underwent computed tomography (CT) scan of the abdomen which revealed findings consistent with fecal impaction and pneumatosis intestinalis of the distal descending colon. He was taken to the operating room where he underwent extensive lysis of liver adhesions thought to have been caused by his prior liver surgery, and exploration revealed only severe colonic impaction. He underwent manual disimpaction of fecal material and gas, peritoneal irrigation, and closure. His initial postoperative course was uneventful, and he was quickly weaned off the ventilator. However, later in the evening he developed chest pain, described as retrosternal sharp to tight feeling, without radiation. Deep inspiration caused worsening of his abdominal pain at the incision site but did not alter his chest pain severity. The patient’s blood pressure and heart rate remained stable. ECG revealed inferior ST elevations with reciprocal ST depressions in the anterior leads suspicious of myocardial injury (Figure
Initial electrocardiogram, showing inferior ST-segment elevations in II, III, and aVF with reciprocal ST-segment depressions in the anterior leads (V1–V4). Arrowheads show PR depression in the inferior leads, with corresponding PR elevation in aVR. Arrows show the downsloping ECG baseline from one QRS complex to the following PR-segment (Spodick’s sign) in the inferior leads, with corresponding upsloping ST-segment depression in the anterior leads (“reverse” Spodick’s sign).
Repeat electrocardiogram on the following morning showing return of the ST-segments to baseline.
Barnes and Burchell [
Characteristic ST and T-wave abnormalities and evolution patterns have long been observed in patients with postinfarction regional pericarditis [
Regional pericarditis has also been observed in the absence of infarction. Youssef et al. [
The American Heart Association, American College of Cardiology Foundation, and Heart Rhythm Society (AHA/ACCF/HRS) guidelines [
Although the absence of elevated cTnI may help differentiate pericarditis from myocardial infarction, cTnI elevation is often observed in viral or idiopathic acute pericarditis [
Our patient developed early postoperative inferior ST elevations, together with reciprocal anterior ST depressions, suggestive of an acute inferior ST-elevation myocardial infarction (Figure
Pericarditis is a common condition with clinical and electrocardiographic features which can mimic ACS. The subtle differences between the two conditions are often overlooked due to the fear of missing the more serious diagnosis of ACS and the window for timely reperfusion. Even though ancillary tests, such as echocardiography and cardiac biomarkers, can aid in diagnosing pericarditis or excluding ACS, careful attention to specific characteristic findings on the ECG remains the mainstay of initial and timely recognition and triage of patients to avoid the potentially harmful consequences of inappropriate therapy. Helpful electrocardiographic features in differentiating acute pericarditis from ACS include PR-segment depression, a downsloping ECG baseline from one QRS complex to the following PR-segment (Spodick’s sign), and, in regional pericarditis, reciprocal ST changes (“reverse” Spodick’s sign).
The authors declare that there is no conflict of interests regarding the publication of this paper.