Masters Case #02: 60 Year Old Female – Chest Pain, Hx of Pericarditis

***Update: The conclusion for this case is now posted here.***

This is the second in our occasional series of Masters Cases. These are some of the toughest ECG’s we have seen and that is reflected in both the level of responses that are expected along with the depth of the discussions that will entail. For a taste of how these play out check out the conclusion to the Case #01.

As with the first case, this one was also submitted by Dr. Bojana Uzelac from Serbia. Her country, along with much of the Balkans, recently experienced flooding on a scale that has not been seen in anyone’s lifetime. In an email she described it to me as:

“For my 34 years I have seen war, bombing, earthquakes, fires, political revolution…We had regional floods in past and we managed to recover from them. But something like this – no one has ever seen in Serbia! I can’t explain you with words about size of our disaster…”

Please keep the people there in your hearts.

 

A 60-year-old female presents with a chief complaint of chest pain.

The pain started at rest one hour prior and was associated with shortness of breath, nausea, and weakness. At present the pain has subsided substantially although she still appears exhausted and admits: “There is some mild discomfort, but it’s not pain.”

She can’t quantify the pain, but based on your experience you would assume it started off at maybe an 8/10 (she’s the stubborn type who would never admit to 10/10 pain) and is now a 1 or 2/10.

Her past medical history is significant for type II diabetes, hypertension, and “chronic bronchitis.”

Importantly, she was hospitalized almost a year ago for exudative pericarditis and her husband is worried that she could be experiencing that again. He is unsure of the etiology of the prior pericarditis but it doesn’t sound like it was secondary to tuberculosis, so at least that’s good.

Physical exam shows a well-nourished, slightly overweight, middle-aged female. Lung sounds are mostly clear with some scattered wheezes bilaterally. Heart sounds are a bit quiet but audible. Pulse is strong and regular at the radial arteries and her skin is warm and dry, though a bit pale.

Vitals: HR 61 bpm, RR 14 /min, SpO2 97% on room air, BP 150/90 mmHg, and temp 37.2 C.

You perform the following ECG in the field:

Masters Case 02 - Bojana Uzelac - EMS 12-Lead

Because of an error in the electronic medical record you are unable to pull up a scanned copy of her old EKG, but the report is available and states there was a right bundle branch block and left-anterior fascicular block.

The patient is hesitant to go to the hospital as she feels much better. In-fact, she looks a bit better than when you first arrived.

How would you manage this case? Is this pericarditis? Does she have a coronary culprit? What is the likely clinical course?

 

Please remember that the Masters Series is designed to push the abilities of experienced ECG readers. Responses are expected to be detailed and supported by your understanding of the complex interplay of ECG findings. One sentence replies will simply be deleted. With that, happy reading, and good luck!

9 Comments

  • Brian says:

    Case for Ischemia/infarct- The ST segements in the inferior leads show some minor elevation and straight ST segements with symmetrical T wave inversion. There is also a pathologic Q wave in V1. And aVL looks like it could have some reciprocal changes.
    The ST segements in v1-v4 bother me a bit. They are slightly depressed/flat. Is this posterior involvement of an infarct?

    Case for Pericarditis-There is PR depression in v1-v4, there is some PR elevation in aVR. Spodicks sign seems to be present in v2-v5 and II, III, and avf.

    I think this is an inferior posterior STEMI and Pericarditis.

  • Jan says:

    So – here is a try from Germany:

    Rhythm is normal sinus rhythm as there are normal p waves all over the strip without any findings. Normal PQ intervals at any point.

    QRS is narrow with abnormal findings in lead 2 and V2.
    (Ss configuration in lead 2 and Rr configuration in lead V2). Pathologic Q wave in V1. These might correlate to the known older cardiac problems.
    PR depression in V2 – V4. I see PR elevation in aVR, too.

    I am a bit concerned about the t wave configuration in lead V2. This t wave is definitely elevated and there might be a bit of st elevation. Not enough to meet STEMI criteria, but this might be an indicator for developing ischemia.

    Im am also concerned about the qrs axis, as they round about -30° to -90°. This is definitely not a normal finding.
    It might be related to the older bronchitis, but it might also be acute.

    Even though I don’t have a specific finding till now, I would go for V4R and V7 – V9 to check for additional findings.

    I can’t definitely rule out pericarditis by the ecg, but it should not produce a sudden onset of pain. As my most acute finding in this ecg are the changes in V2 I would call it a near-by occlusion of distal LAD, probably unstable angina. Even though not acute, the patient will need to go to the cath lab.

    I’m really looking forward to the other comments…

  • Jennifer Henderson says:

    Unstable angus, cath lab and do a posterior ECG

    • I’m working on the conclusion now and I think you’re going to like it. Well done on your read! I’m pretty sure you were the only person to pick up on the key to the diagnosis.

  • Eric says:

    Sinus rhythm. QRS looks like RBBB+LAFB, although there are Q-waves in V1-V2.

    The ST-segments in the inferior leads look highly suspicious with straight slightly upsloping ST-segments and terminal T-wave inversion. There may be some minor ST-elevation at the J-point. Upon scrutinization, aVL does seem to have some very slight reciprocal changes as well. The T-wave changes in the anterior precordials may be due to posterior reperfusion t-waves.

    Inferoposterior STEMI with reperfusion does appear most likely and is compatible with the clinical scenario. Obviously, repeat EKGs would be of great value. I would also be somewhat concerned about hyperkalemia with those anterior t-waves, but less so than for MI.

    Perhaps those Q-waves in V1-V2 are old, they do not seem to fit with the above scenario.

    There is indeed some ST-depression in several leads and there may be elevation in aVL and aVR. The rest of the EKG is not very impressive for pericarditis. I’m thinking there may be some atrial involvement of the infarction.

    Looking forward for the other comments and the answer.

  • Steve says:

    Pericarditis was a consideration, there is evidence of spodicks sign however not consistent enough even with the same lead for me to feel confident and certainly not very pronounced. Also considered some low voltage in V1 to V3 being less than 30 mm which would indicate some effusion, but still borderline at best. The pt’s HX makes us look deep and tricks us into trying to find these things.

    There does seem to be some elevation in aVR, that with additional t wave inversion in multiple leads and possible hyper acute t wave in V2, I would have to treat this as LMCA until proven otherwise.

  • Besides the sinus rhythm, RBBB, LAFB, and septal Q-waves (old MI likely), there is nothing specifically acute about this ECG. There is a downsloping ST segment in V3, and other non-specific T-wave abnormalities, but nothing diagnostic. There is a somewhat long ST segment and perhaps peaked T’s, so I want to rule out hypocalcemia and hyperkalemia, but the findings are not anywhere near diagnostic of these conditions.

  • Hyunjung Park says:

    a comment from Korea.
    I want look Q waves, ST segments and T waves in V1,V2
    Normally, ST segments are depressed in V1-2, T waves are inverted when someone has RBBB.
    If she didn’t have RBBB, STsegments and Twaves would be in normal range (v2’s is a little bit tall, but not serious), but we have to consider her RBBB.
    So My opinion is that she has ST segment elevation and Tall T waves with abnormal Q waves in V1,V2.

  • Nick says:

    Nsr with a rbbb q wave in v1, st changes in II, AVF and v6, inverted t waves in III and AVF cannot rule out pericarditis or ischemia. Possible electrolyte imbalance hyperkalemia so I really want to see a CMP, troponin, pro-BNP CBC/diff an echo, a shoot a right sided ECG as well and repeat the 12 lead in 15 min. If she can take asa I’m giving it as well as o2.

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