Ep 166 Pericarditis and Cardiac Tamponade

In this Part 1 of our two-part series on pericarditis and myocarditis, Anton is joined by Walter Himmel, EM doc at North York General and Paul Dorian cardiologist, researcher, and educator at St. Michael’s Hospital in Toronto (with a short visit from @ECG Cases Jesse McLaren). They answer questions such as: why should pericarditis be considered a diagnosis of exclusion? Which clinical features are most useful in the diagnosis of pericarditis? What are the most common pitfalls in the ECG interpretation of a patient suspected of pericarditis? What are the best ways to differentiate the ECG of pericarditis from that of MI and early repolarization? How is uncomplicated viral pericarditis treated differently compared to pericarditis of other etiologies? Why is it so important to include colchicine as part of the treatment of pericarditis? Which patients with pericarditis should be considered for admission? and many more...



Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Kate Dillon, edited by Anton Helman March, 2022

Cite this podcast as: Helman, A. Himmel, W. Dorian, P. Pericarditis and Cardiac Tamponade. Emergency Medicine Cases. March, 2022. https://emergencymedicinecases.com/pericarditis-cardiac-tamponade. Accessed [date]

Go to part 2 of this 2-part podcast on pericarditis and myocarditis

Pericarditis as a diagnosis of exclusion

Pericarditis should be considered a diagnosis of exclusion, after ruling out the big chest pain killers (MI, PE, aortic dissection, esophageal rupture, and tension pneumothorax), because it can be easily confused with these more time-sensitive, deadly diagnoses. Avoid premature closure!

The following features are suggestive of pericarditis, but none alone have good enough test characteristics to rule it in or out.

Clinical features of pericarditis















Pericarditis diagnostic criteria and evaluation

The diagnosis of pericarditis requires 2/4 of the following criteria:



* Chest pain – typically sharp, pleuritic, positional (>80- 90% of cases)

* Pericardial rub on auscultation ( 5mm in pericarditis

* ST depressions in V1 and aVR favor pericarditis

* aVL ST segment is typically elevated in pericarditis while aVL ST segment depression is highly specific for inferior MI

* Comparison of ST elevation in leads II and III may help differentiate STEMI from pericarditis



* ST elevation II > ST elevation III favors pericarditis

* ST elevation III > ST eleveation II is highly suspicious for inferior STEMI





* Spodick’s sign is seen in approximately 80% of patients with acute pericarditis (and in 29% of patients with all stages of pericarditis) and 5% of STEMIs; it is characterized by down-sloping from the T wave to the QRS segments with the terminal PR segment depressed; this is best seen in lead II and the lateral precordial leads.





ECG findings of pericardial effusion that may be associated with pericarditis:



* Low voltages (also seen in COPD, and patients with obesity)

* Electrical alternans



Pitfall: There are no ECG findings that are 100% sensitive for specific to differentiate pericarditis from MI underlining the importance of approaching pericarditis as a diagnosis of exclusion

ECG findings to help differentiate pericarditis from early repolarization

Early repolarization is typically a phenomenon of young, healthy, tall athletes. This population overlaps with that of pericarditis.

 Example: Notched J-Point in early repolarization