What are the EKG findings and treatment options for pericarditis?

EKG Findings and Treatment Options for Pericarditis

EKG Findings in Pericarditis

The classic EKG findings in pericarditis include diffuse, widespread ST-segment elevation in multiple leads, PR-segment depression (except in aVR where PR elevation may occur), and ST-segment depression in lead aVR, reflecting epicardial inflammation. 1

These EKG changes typically follow a temporal pattern that can be divided into four stages:

1. Stage 1: Diffuse, concave upward ST-segment elevation in multiple leads with PR-segment depression
2. Stage 2: Normalization of ST and PR segments
3. Stage 3: T-wave inversions
4. Stage 4: Normalization of the EKG

Important considerations regarding EKG findings:

• EKG changes are present in only about 60% of pericarditis cases 2, 3
• Changes can be temporally dynamic and evolve rapidly during the disease course 3
• EKG may be normal at presentation or for days after the initial chest pain 3
• Serial EKGs may reveal specific patterns during new episodes of chest pain 3

Differentiating from Acute Coronary Syndrome:

• Pericarditis: Diffuse ST elevation without reciprocal ST depression
• ACS: Localized ST elevation with reciprocal ST depression 1

Diagnostic Approach

The European Society of Cardiology recommends that diagnosis of pericarditis requires at least 2 of 4 criteria 2, 1:

1. Pericarditic chest pain
2. Pericardial friction rub
3. New widespread ST-elevation or PR depression on ECG
4. Pericardial effusion (new or worsening)

Additional supporting findings include:

• Elevated inflammatory markers (CRP, ESR, WBC)
• Evidence of pericardial inflammation on imaging (CT, CMR) 2

Treatment Options for Pericarditis

First-Line Treatment:

1. NSAIDs - First-line therapy for most patients 2, 4

   • Aspirin: 750-1000 mg every 8 hours for 1-2 weeks, then taper
   • Ibuprofen: 600 mg every 8 hours for 1-2 weeks, then taper

2. Colchicine - Should be added to NSAIDs 2, 4

   • 0.5 mg twice daily (or 0.5 mg once daily for patients <70 kg or intolerant to higher doses)
   • Duration: 3 months for acute pericarditis, 6 months for recurrent pericarditis
   • Reduces risk of recurrence when combined with NSAIDs

Second-Line Treatment:

Corticosteroids - Reserved for specific situations 2, 4:

• Contraindications to NSAIDs
• Pregnancy beyond 20 weeks
• Autoimmune etiology
• Incomplete response to NSAIDs and colchicine

Note: Corticosteroids are not recommended as first-line therapy for acute pericarditis 2

Risk Stratification and Management:

High-Risk Features (requiring hospitalization) 2:

• Fever >38°C
• Subacute course (symptoms developing over several days/weeks)
• Large pericardial effusion (>20 mm) or cardiac tamponade
• Failure to respond to NSAIDs within 7 days
• Immunosuppression
• Trauma
• Oral anticoagulant therapy
• Myopericarditis

Low-Risk Patients:

• Can be managed as outpatients with empiric anti-inflammatories
• Follow-up after 1 week to assess treatment response 2

Monitoring:

• CRP should be used to guide treatment duration and assess response 2
• Follow-up echocardiography to monitor effusion resolution

Special Situations

Tuberculous Pericarditis:

• In endemic areas, empiric anti-TB chemotherapy is recommended for exudative effusions
• Standard anti-TB drugs for 6 months to prevent constriction
• Pericardiectomy if no improvement after 4-8 weeks of therapy 2

Neoplastic Pericardial Disease:

• Systemic antineoplastic treatment for confirmed neoplastic etiology
• Extended pericardial drainage to prevent recurrence
• Consider intrapericardial cytostatic/sclerosing agents 2

Physical Activity Restrictions:

• Restrict physical activity beyond ordinary sedentary life until symptoms resolve and CRP normalizes
• Athletes should return to competitive sports only after complete resolution of symptoms and normalization of diagnostic tests 2