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Category: Visual EM

  • Acute Pericarditis: Electrocardiogram

     

    HPI:

    A 22 year-old male presented to the emergency department with a chief complaint of retrosternal chest pain that started yesterday. He described the pain as a constant, sharp and pleuritic. The pain was worsened by lying flat, and improves with  leaning forward.  He  reported having a  sore throat and other cold symptoms earlier in the week. The patient’s exam was notable for a faint pericardial friction rub. A bedside echocardiogram demonstrated normal cardiac function without pericardial effusion. The patient’s ECG is shown.

    Significant findings:

    The ECG shows diffuse ST- elevation. The patient also has mild PR-depression, most notably in the inferior and lateral leads. The patient also has minimal PR elevation in lead aVR. The patient was diagnosed with acute pericarditis (ECG stage 1).

    Discussion:

    Pericarditis is inflammation or infection of the pericardial sac. There most common etiologies are viral or idiopathic1,2. While it is rarely fatal, acute pericarditis can cause severe, disabling pain2. Furthermore, concomitant myocarditis can cause significant morbidity and mortality. Classic ECG findings include diffuse ST-elevations and PR- segment depression, without reciprocal ST-segment depression (as shown in this image).   The ECG of pericarditis may move through various stages when followed over time1,2. These include stage 1: diffuse ST-elevations with concave-upwards contour, PR- depressions (most common in II, aVF, V4-6); stage 2: ST segments become isoelectric and T waves flatten; stage 3: symmetric T wave inversion throughout ECG; and stage 4: ECG normalization2. These ECG changes have variable sensitivity and specificity depending on the stage, with less than 50% of patients progressing through the classic stages2.

    Topics:

    Cardiology, Cards, ECG, ST elevation, acute pericarditis, abnormal ECG, PR depression

    References:

    1. Colletti JE, Tabas JA. Cardiovascular disorders in emergency medicine. In: Schofer JM, Mattu A, Kessler C, Lu LN, Parker T, Rogers R, et al. eds. A Focused Review of the Core Curriculum. 2nd Milwaukee, WI: American Academy of Emergency Medicine Resident and Student Association; 2015:237-242.
    2. Mattu A, Martinez JP. Pericarditis, pericardial tamponade, and myocarditis. In: Adams JG, Barton ED, Collings JL, DeBlieux PM, GIsondi MA, Nadel ES, eds. Emergency Medicine: Clinical Essentials. 2nd Philadelphia, PA: Elsevier; 2013:514-523.

  • Atrial Myxoma

    HPI:

    A 52-year-old female presented to the emergency department with lightheadedness and shortness of breath, which had gradually progressed over several months. She denied chest pain. Her only medical history was an atrial myxoma that had been previously removed. Her exam was notable for a “plopping” noise heard on cardiac auscultation.

    Significant findings:

    Bedside ultrasound revealed the presence of a left atrial mass that appeared to be tethered to the mitral valve. The mass was best viewed on ultrasound in the apical four-chamber window with the phased array probe placed over the patients’ point of maximal impact (PMI), with the patient in left lateral decubitus position.  

    Discussion:

    Primary cardiac tumors are rare, estimated to have an incidence of 0.0017 and 0.19 percent1. Approximately three quarters of primary cardiac tumors are benign, and nearly half of these are myxomas. Myxomas can occur in all age groups, however they are more prominent in the third to sixth decades of life. Approximately 75% originate in the left atrium, with the remaining 25% originating in the right atrium and the interatrial septum. Patients’ symptoms are directly related to the size and position of the myxoma. In cases of small tumors, patients maybe asymptomatic, while larger tumors may embolize causing cerebral vascular accidents, vision loss. Severe cases of embolized left ventricular myxomas can cause complete occlusion of the abdominal aorta. Myxomas can also cause intracardiac obstruction, leading to shortness of breath, heart failure, syncope, or more generalized symptoms such as fatigue, fevers, and weight loss. Surgical excision is the treatment of choice.  While CT and MRI may aid in diagnosis, transesophageal echocardiogram (TEE) remains the standard for diagnosis of atrial myxomas, with one study showing a sensitivity of 94% and specificity of 100%2.

    References/Suggestions for Further Reading:

    1. Reynen K. Cardiac myxomas. N Engl J Med. 1995:333(24);1610-1617. doi: 10.1056/NEJM199512143332407
    2. Goldman JH, Foster E. Transesophageal echocardiographic (TEE) evaluation of intracardiac and pericardial masses. Cardiol Clin. 2000;18(4):849-60.