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ORIGINAL ARTICLE
Year : 2008  |  Volume : 9  |  Issue : 3  |  Page : 114-120 Table of Contents     

The role of isolated AVR and V1 reciprocal changes in differentiating acute pericarditis from myocardial infarction


1 Department of Cardiology and Cardiothoracic Surgery, and Department of Internal Medicine, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
2 The Sunnybrook Hospital,Toronto, Ontario, Canada

Date of Web Publication17-Jun-2010

Correspondence Address:
Abdulrahman D Al-Nabti
Department of Cardiology and Cardiothoracic Surgery, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar

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Source of Support: None, Conflict of Interest: None


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   Abstract 

Objectives: The significance of reciprocal changes distribution in acute pericarditis has not been studied yet. We evaluated the significance of reciprocal changes distribution in leads V1 and AVR in differentiating acute pericarditis from myocardial infarction.
Methods: A retrospective case control study done on 240 pateitns wih AP only 76 patients who had ST elevation ECG changes were included in the study, compared to another Control group of 80 patients with documented acute myocardial infarction (AMI).
Results: The reciprocal changes in leads AVR and V1 ± III was the most sensitive and specific ECG findings for the diagnosis of AP, sensitivity of 68% and specificity of 98% P < 0.001. Moreover PR segment depression P < 0.26, ST/T wave ratio P < 0.33, shape of ST segment P = 0.49, ST segment axis P = 0.11, were not found to be sensitive nor specific for the diagnosis of AP. However the diffuse ST segment elevation was suggestive of AP with sensitivity of 51% and specificity of 97.5%, P < 0.001.
Conclusion: This study showed that the reciprocal changes in the leads V1, AVR, ± leads III are more sensitive and specific than the PR segment depression, ST segment shape, ST/T wave ratio, ST segment axis. For the diagnosis of AP, and it can be useful tool to differentiate AP from AMI.

Keywords: myocardial infarction, pericarditis


How to cite this article:
Al-Nabti AD, Al-Hail KS, Almarri MR, Chun R. The role of isolated AVR and V1 reciprocal changes in differentiating acute pericarditis from myocardial infarction. Heart Views 2008;9:114-20

How to cite this URL:
Al-Nabti AD, Al-Hail KS, Almarri MR, Chun R. The role of isolated AVR and V1 reciprocal changes in differentiating acute pericarditis from myocardial infarction. Heart Views [serial online] 2008 [cited 2020 Nov 30];9:114-20. Available from: https://www.heartviews.org/text.asp?2008/9/3/114/63760

Abbreviations: AP = Acute pericarditis, AMI = Acute myocardial infarction



   Introduction Top


Acute pericarditis is an inflammation of the pericardium characterized by chest pain, pericardial friction rub, and serial electrocardiographic changes, In most cases of acute pericarditis, the pericardium is acutely inflamed and has an infiltration of polymorphonuclear (PMN) leukocytes and pericardial vascularization. Often, the pericardium manifests a fibrinous reaction with exudates and adhesions. The pericardium may develop a serous or hemorrhagic effusion. A granulomatous pericarditis occurs with tuberculosis, fungal infections, rheumatoid arthritis (RA), and sarcoidosis, however, the most common cause is usually post Viral infection, luckily it has a benign course with low mortality.


   Electrocardiographic changes Top


AP resulted from acute inflammation in the pericardium and that leads to ventricular repolarization abnormalities presented usually as diffuse ST segment elevation and atrial inflammation leads to widespread PR segment depression in all leads except in AVR lead, where the opposite ST depression and associated PR segment elevation is expected to take a place, as the inflammation subsided, the electrocardiographic changes transformed from acute phase to chronic phase this will leads to further ST segments elevation resolution and eventually leads to ST segments depression and T wave inversion over periods of days to weeks then eventually all the ST & T changes fades away with normalization of the electrocardiogram, in some cases the ST &T changes became chronic changes that last for months or years.

AP, has been estimated to be responsible for up to 5% of non cardiac chest pain admissions to the emergency room [1] , there are few reports of cases series with small numbers of patients reported on the electrocardiographic signs in AP alone or cases series to differentiating between AP and AMI, but didn't address specifically the reciprocal changes accuracy in AP. The presence of PR segment Depression, has only been studied in AP patients [1],[2],[7],[9] , but it was not addressed in Acute presentation particularly during the acute phase of injury where we expect to see a lot of ST/T dynamic shifts which in turns affect the PR segment and the reciprocal changes, in addition to this it is also reported in variety of condition, first of which is AMI, in addition to arrhythmias, early repolarization [3],[4],[5],[6] .

Acute pericarditis may present early before they develop the full picture of pericaritis with undifferentiating chest pain and significant ST segment elevation [5],[6],[7],[8] . AP present with pluritic chest pain and pericardial rub that usually is not audible in the 1st day of presentation [9],[10] , a more recent study by, Jae K.oh and his colleagues from Mayo Clinic, studied one hundred and eighty patients with Acute pericarditis (AP) divided them into two groups, group one showed normal or ST segment depressions 48%, group 2 presented with chest pain and ST segment elevation, in 52%, in group 2, 18% coronary angiography was performed to role out AP, 6% received thrombolysis, administration of ASA, Nitrates, anti thrombin was also higher in this group, pericardial effusion was present in 34% in group 2 vs 12.6% group 1, evolution to cardiac tamponade in 13.8% vs 3.4%, P value 0.02, and pericardiocentesis (16.3% vs 5.7%), and this stress once again the importance of differentiating the AP from AMI [8] .


   Method: Protocol and Approval Top


The ethics and research committees of the Sunnybrook and Women's Hospitals, Toronto, approved a retrospective case control study on patients who presented with early AP to the Emergency Departments of Sunnybrook & Women's College Health Sciences Center over the period 1993 until 2000. The hospitals are run by the Ministry of Health, are affiliated to the University of Toronto and are open to all sections of the general public. The medical charts were reviewed of 240 patients with a diagnosis of acute pericarditis. These we divided into two groups, 164 with normal ECG or ST segment depression in Group A and 76 with ST segment elevation of more then 1mm in Group B.

The diagnosis of AP, was obtained from the files as the main reason for admission, AP with concomitant AMI diagnosis ,or the presence of any of the finding that may suggest AMI, this will exclude the patients from the study [18] . The AMI group included patients with anterior, inferior or antero-lateral wall MI 1 mm ST elevation in two consecutive pericardial leads or 1mm in limb leads and a clear diagnosis of AMI supported by coronary angiogram results and/or biomarker release. Coronary angiogram alone confirmed some of the diagnoses. Patients with posterior wall AMI and or AMI with LBBB or RBBB, and a masked ST elevation were excluded because the purpose of this study was to address the acute ST/T dynamic shift in the first few hours, and specifically. the patterns that can be used to distinguish one from the other during the acute phase.


   Inclusion criteria Top


  1. Chest pain on presentation,
  2. electrocardiographic changes with ST segment elevation 1mm in two or more consecutive leads,
  3. clear discharge diagnosis of AMI or AP supported with other ancillary testing such as serial CK or Troponins or angiography.

   Exclusion criteria Top


  1. Patients with RBBB or LBBB, or posterior MI
  2. Patients without an initial EKG
  3. Unclear diagnosis at discharge
  4. ST elevation < 1mm.

   Methods Top


The electrocardiographic changes in the two groups were compared, AP and AMI, for the presence of PR segment depression [7],[9] , ST segment shape [9],[10],[19] , ST/T wave ratio [8],[32] , ST segment axis [24],[25],[29] and the distribution of ST segment elevation and reciprocal changes, with the above factors being defined as:

  1. PR Segment: from the beginning of the P wave to the beginning of the QRS complex, if it is depressed >1mm, then it is suggestive of acute pericarditis [9] .
  2. ST/T: ST/T ratio, if less than 25% it is considered positive and suggestive of early repolarization [26] .
  3. Convex ST segment: Outward plugging of the ST segment with elevation, suggestive of AMI.
  4. Concave ST Segment: Inward ST segment plugging of the ST segment with elevation suggestive of AP.
  5. ST segment Axis: Based on the transition point of the QRS complex on the pericardial leads, Vertical ST segment Axis: The transition occurring beyond V3, this would be suggestive of AMI, Horizontal axis: If the transition occurs early on V3 or V2 this would be suggestive of AP [5],[15],[16] .
  6. ST segment elevation: We divided all the EKG's with ST elevation into three groups based on the number of territories involved electrocardiographically:

    1. Diffuse ST segment elevations
    2. ST segment elevation in one territory [20],[21]
    3. ST segment elevation in two territories
  7. Reciprocal changes: We also divided the electrocardiographic reciprocal changes in both AP and AMI into three subgroups:

    1. Reciprocal changes limited to AVR and V1 ± III
    2. Reciprocal changes in other territories (other than AVR, V1, III)
    3. No reciprocal changes group.


The EKGs, in no particular order, were reviewed by two physicians unaware of the diagnoses. They looked specifically at the electrocardiographic signs for AP and AMI (mentioned above) that helped differentiate between AMI and AP. All interpretations were entered into an Excel database.

Analysis The data were analyzed using SSPS, USA. Information handling and analysis were done independently by the Institute of Clinical Evaluative Sciences (ICES) in Ontario. We used chi square, Fisher exact test to examine the variables in both groups with p < 0.05 as the cut-off point for significant difference. We also derived the likelihood ratio, sensitivity, specificity and odd ratios for all the eleven variables.

We divided the variables into clinical Variables: 1) Age, 2) gender, 3) type of chest pain, 4) presence of pericardial rub and electrocardiographic variables, 1) PR segment depression. 2) ST segment axis. 3) ST segment/T wave ratio. 4) ST segment elevation distribution. 5) reciprocal changes distribution. 6) Concave ST segment elevation. 7) Convex ST segment elevation.


   Results Clinical Variables Top


Sex and Age: The AMI group was predominantly male with 72 males (90%) and eight (10%) females with a mean age of 64 years (37-87 years). The AP group contained 34 (44.5%) males and 42 (55.5%) females with a mean age of 57 years (19-87 yrs).

Type of Chest Pain: 19 of 76 patients (25%) in the AP group complained of non-pleuritic chest pain while 57 (75%) complained of pleuritic chest pain.

Pericardial Rub: Pericardial rub was detected in (31.5%) with AP during their stay in the hospital; none of the patients with acute MI had any rub on admission.


   The Electrocardiographic Changes Top


  1. Distribution of ST segment elevation [Table 1]: This was divided into three groups based on the number of territories involved with ST elevation. Diffuse ST elevations in all the territories, anterior, lateral and inferior, would favor a diagnosis of AP with a sensitivity of 51% and specificity of 97.5%, p < 0.0001, but if only one territory is involved, this would favor a diagnosis of AMI, with a sensitivity of 61%, and specificity of 98%.
  2. Reciprocal changes in AVR,V1 with or without reciprocal changes in lead III: [Table 2]: The patients with AP showed reciprocal changes mainly in AVR, V1 leads alone. However these reciprocal changes may extend to lead III, or may not include it in some other cases, but are always accompanied by reciprocal changes in leads V1, AVR when lead III is involved sparing the AVF lead, for that reason we added the involvement of reciprocal changes in lead III in addition to the V1, AVR leads. The sensitivity and the specificity, for the presence of reciprocal changes in AVR, V1, in addition to lead III in AP was 68%, 98% respectively.[Table 3]



   Other Electrocardiographic Signs Top


[Table 4]: Table PR segment depression, ST/T wave ratio, ST segment shape and ST segment axis were compared in both groups and surprisingly none of these well described signs could provide enough statistical power, indicating that none of these signs is reliable enough to confirm or refute the AP diagnosis.(p = NS).

[Table 4]: Showed the reciprocal changes, sensitivity 68% and specificity 98% (p-value = < 0.001), while PR segment depressions were not specific nor sensitive (p-value NS).

Study Limitation: There are number of limitations in this study, first the focus sole on AMI and AP, excluding other subgroups that can present with diffuse ST elevations, such as patients with early repolarization. Also this study was retrospective and hence it inherited all the errors of retrospective analysis and the possibility of incomplete information was an issue in spite of our efforts to ensure that the data was complete.


   Discussion Top


The purpose of this study was to evaluate the reciprocal changes during ST segment shift, particularly during the early phase when both AP and AMI can present in similar way. The electrocardiographic changes that accompany pericarditis consist of diffuse ST elevation, the source of which is thought to be local inflammatory changes in the pericardium, Teh, Kilpatrick et al [22],[26] were able to show by electrcardiographic surface mapping study on groups of normal subjects and those with AP and AMI, show that AP electrical current flows with unique patterns of electrical discharge, unlike the normal and the AMI current flows. They showed that the electrical flow in AP tends to start from both the endocardium and the surfaces of both ventricles causing diffuse ST segment elevations and then they drain backward into the right atrium and the great vessels causing a negative charge or a reciprocal ST segment depressions in the corresponding leads, V1, AVR [7],[23],[24] .

We should also remember that no test will ever be a substitute for a good history and physical examination. Interestingly, we found that 25% of AP patients might not have pleurisy although, as has been shown in other studies [5],[6],[8],[9],[13] , pericardial rub is difficult to detect and only 25-30% patients with AP will have an audible rub. The role of troponin levels in patients with acute pericarditis remains to be evaluated, a recent report showing some promising results for the use of troponin as an adjunctive new marker in the diagnosis of AP [25] .

In the future we are planning a prospective study to validate these findings by using an algorithm [Figure 1] and [Figure 2] to differentiate AP from AMI on patients presenting with acute chest pain and ST segment elevation. We shall evaluate the patients for the nature of the chest pain (pleuritic or non-pleuritic), the presence or absence of pericardial rub and electrocardiographic findings focusing on the presence of diffuse ST segment elevation and/or limited reciprocal changes in AVR, V1 ± III in the hope that the findings will help reduce unnecessary numbers of AP who got admitted as AMI, and treated as such, which have a negative impact on those patients benign course of AP.

Acknowledgment: The authors would like to thank Dr. Paul Szalay from the Ontario Institute of Evaluative Sciences (ICES), for his help with Analysis of the Data, Toronto, Ontario, Canada.[33]

 
   References Top

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3.Ly QH, Sauve C, Lalonde G. Acute pericarditis with transient constriction. Can J Cardiol. 2001;17(9):973-976.  Back to cited text no. 3      
4.Diamond T. The ST segment axis: A distinguishing feature between acute pericarditis and acute myocardial infarction. Heart & Lung1985;14(6):629-631.  Back to cited text no. 4      
5.Brady WJ, Perron AD, Martin ML, Beagle C, Aufderheide TP. Cause of ST segment abnormality in ED chest pain patients. Am J Emerg Med. 2001;19(1):258.  Back to cited text no. 5      
6.Aikat S, Ghaffari S. A review of pericardial diseases: clinical, ECG and hemodynamic features and management. Cleve Clin J Med.2000;67(12):903  Back to cited text no. 6      
7.Bruce MA, Spodick DH. Atypical electrocardiogram in acute pericarditis: Characteristics and prevalence. J Electrocardiol 1980;13(1):61-66.  Back to cited text no. 7      
8.Chan TC, Brady WJ, Pollack M. Electrocardigraphic manifestations: Acute myopericarditis. J Emerg Med.1999;17 (5)85-72.  Back to cited text no. 8      
9.Olalla C,Mookadam F, Casaclang-Verzosa G,Ting H,Rihal S C,Oh K J.JACC 2006,47(4),Supplement A :90A-91A.  Back to cited text no. 9      
10. Mehta M, Jain AC, Mehta A. Early repolarization Clin Cardiol.1999;22 (2): 59-65.  Back to cited text no. 10      
11. Mewar SH, Shamsi SN, Anjur-Kapali N, Spodick DH. Acute Pericarditis. Curr Treat Options Cardiovasc Med. 1999; 1(1):73-77.  Back to cited text no. 11      
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13. Ly QH, Sauve C, Lalonde G. Acute pericarditis with transient constriction. Can J Cardiol. 2001; 17(9):973-6.  Back to cited text no. 13      
14. Marinella MA. Electrocardiographic manifestations and differential diagnosis of acute pericarditis. Am Fam Physician.1998;57(4):699-704. Review.  Back to cited text no. 14      
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17. Diamond T. The ST segment axis: A distinguishing feature between acute pericarditis and acute myocardial infarction. Heart & Lung1985;14(6):629-631.  Back to cited text no. 17      
18. Kouvaras G, Soufras G, Chronopoulos G, Giannopoulou A, Pisimisis E, Cokkinos DV. The ST segment axis as a differential diagnostic feature between acute pericarditis and acute inferior myocardial infarction. Angiology.1990; 41(3): 207-212.  Back to cited text no. 18      
19. Kilpatrick D, Walker SJ, and Bell AJ.Impportance of Great Vessels in the genesis of the electrocardiogram Circ Res.1990; 66(4):1081-1087.  Back to cited text no. 19      
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22. Chan TC, Brady WJ, Pollack M. Electrocardigraphic manifestations: Acute myopericarditis. J Emerg Med.1999; 17 (5)85-72.References cont'd  Back to cited text no. 22      
23. Adler Y, Finkelstein Y, Guindo J, Rodriguez de la Serna A, Shoenfeld Y, Bayes-Genis A, Sagie A, Bayes de Luna A, Spodick DH. Colchicine treatment for recurrent pericarditis. A decade of experience. Circulation.1998;97(21):2183-2185.  Back to cited text no. 23      
24. Teh BS, Walsh J, Bell AJ, Walker SJ, Kilpatrick D. Electrical current paths in acute pericarditis. J electrocardiol1993;26(4):291-300.  Back to cited text no. 24      
25. Mirvis DM.Anatomic basis for the injury current producing ST-segment shift on the body surface. J Electrocardiol.1992;2 suppl:41-43.  Back to cited text no. 25      
26. Kilpatrick D, Walker SJ, and Bell AJ.Impportance of Great Vessels in the genesis of the electrocardiogram Circ Res.1990; 66(4):1081-1087.  Back to cited text no. 26      
27. Bonnefoy E, Godon P, Kirkorian G, Fatemi M, Chevalier P, Touboul P. Serum cardiac troponin I and ST-segment elevation in patients with acute pericarditis. Eur Heart J. 2000; 21(10):832-836.  Back to cited text no. 27      
28. Kilpatrick D, Bell AJ, Briggs C. Assessment of reperfusion in Myocardial infarction by body surface electrocardiographic mapping. J Electrocardiol.1993; 26(4):279-289.  Back to cited text no. 28      
29. Mirvis DM.Anatomic basis for the injury current producing ST-segment shift on the body surface. J Electrocardiol.1992;2 suppl:41-43.  Back to cited text no. 29      
30. Adler Y, Finkelstein Y, Guindo J, Rodriguez de la Serna A, Shoenfeld Y, Bayes-Genis A, Sagie A, Bayes de Luna A, Spodick DH. Colchicine treatment for recurrent pericarditis. A decade of experience. Circulation.1998;97(21):2183-2185.  Back to cited text no. 30      
31. Evans TG Jr. Diagnostic Dilemma. Am J Med. 2000;109(3):248-25530:Bell AJ, Briggs CM, Nichols P, Kilpatrick D. Relationship of ST segment elevation to evantual QRS loss in acute anterior myocartdial infarction. J Electrocardiol. 199;26(3):177-185.  Back to cited text no. 31      
32. Korneich F.body surface mapping:a paractical cardiac image tool? Acta cardiol.1988;43(6)639-652.  Back to cited text no. 32      
33. Wanner WR, Schaal SF, Bashore TM, Norton VJ, Lewis RP. Repolarization variant vs acute pericarditis, A prospective electrocardiographic and echocardiographic evaluation. Chest. 1983(2):180-184.  Back to cited text no. 33      


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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