Can a 31-year-old female patient with left-sided chest pain and left shoulder pain have ECG findings indicative of pericarditis?

ECG Findings in Pericarditis

Yes, pericarditis has characteristic ECG findings, but they are present in only about 60% of cases, and a 31-year-old female with left-sided chest pain and left shoulder pain can show these changes if pericarditis is present. 1

Classic ECG Patterns

The hallmark ECG findings include widespread ST-segment elevation (concave upward) and PR-segment depression. 1 These changes reflect inflammation of the epicardium rather than the pericardium itself, since the parietal pericardium is electrically inert. 1

Specific ECG Characteristics:

• Diffuse, concave upward ST-segment elevations without reciprocal changes (distinguishing it from acute MI) 2
• PR-segment depressions across multiple leads 2
• T-wave inversions may develop later in the disease course 2
• Changes are typically widespread rather than localized to a specific coronary territory 1

Critical Clinical Context

ECG changes occur in only 24.5% to 60% of confirmed pericarditis cases, making their absence insufficient to rule out the diagnosis. 3 In a prospective study of 110 pericarditis patients, only 27 (24.5%) demonstrated ECG changes. 3

Important Caveats:

• The ECG may be completely normal at initial presentation or for days after symptom onset 4
• Serial ECGs are essential as changes evolve rapidly and can be temporally dynamic 4
• ECG changes are influenced by disease severity, timing of presentation, degree of myocardial involvement, and treatment initiation 4

Diagnostic Algorithm for Your Patient

For a 31-year-old female with left-sided chest pain and left shoulder pain:

1. Obtain immediate ECG looking specifically for widespread ST elevation and PR depression 1, 2

2. Apply the ESC diagnostic criteria - diagnosis requires at least 2 of 4 criteria: 1

   • Pericarditic chest pain (sharp, pleuritic, positional)
   • Pericardial friction rub
   • New widespread ST-elevation or PR depression on ECG
   • Pericardial effusion (new or worsening)

3. Perform transthoracic echocardiography in all suspected cases regardless of ECG findings to detect effusion and evaluate for complications 2

4. Check inflammatory markers (CRP, ESR, WBC) and cardiac troponins 1

Critical Differential Diagnosis Consideration

Left shoulder pain is a classical feature of pericarditis (radiation to trapezius ridge), but left arm pain raises concern for myocardial involvement or acute coronary syndrome. 5

Key Distinguishing Features:

• Pericarditis pain: Sharp, pleuritic, improves sitting forward, radiates to neck/back/left shoulder 5
• MI pain: Left arm radiation more typical, associated with convex (not concave) ST elevation in specific coronary distributions 5
• Myopericarditis: Can present with features of both conditions 5

When ECG Changes Suggest Myocardial Involvement

If ECG changes are present, consider concurrent myocarditis, especially if troponin is elevated (occurs in up to 50% of pericarditis cases). 1, 3 ECG changes were significantly associated with troponin elevation (risk ratio 1.97) in multivariate analysis, suggesting myocardial involvement rather than isolated pericarditis. 3

Cardiac MRI is the most sensitive study (94-100% sensitivity) for confirming myocardial and pericardial inflammation when the diagnosis is uncertain or myocardial involvement is suspected. 5

Prognostic Implications

Importantly, the presence of ECG changes does not worsen prognosis in pericarditis patients and is not associated with increased risk of adverse events. 3 However, ECG changes warrant evaluation for concurrent myocarditis, which may require different management considerations. 3