ECG Case 003

This is fairly simple straightforward case but it reinforced something for me.

4am standby call for a STEMI. At 4am. Was he shovelling snow at 4am?


Chest pain for 9 hours.

[peekaboo_link name=”Diagnosis”]Diagnosis[/peekaboo_link][peekaboo_content name=”Diagnosis”]

There’s ST elevation in a lot of leads – meaning that it would have to be a really funky anatomic variant to explain such a huge territory of infarction. Either that or multiple acute occlusions in different vessels. That’s a give away.

It’s pretty damn saddle shaped. That’s a give away too.

There’s ST depression in aVR. Hmmm.

That was what got me. Because Amal Mattu is such a good teacher I have a whole differential for ST elevation. And I remember that if there’s ST depression on an ECG with ST elevation then I’ve made my diagnosis – it’s a STEMI.

And at 4am  that’s what you remember and what makes you a little uncomfortable calling this as straightforward pericarditis.

You ring cardiology and tell them you think it was just pericarditis but are a little concerned by the ST depression. They come and see the patient and with no wall motion abnormality on echo and no evolution on serial ECGs they call it as pericarditis too.

In pericarditis you’re allowed ST depression in V1 and aVR but nowhere else.

So did Dr Mattu teach us wrong?

Of course not. In fact I was there when he told me at ICEM 2012. I even tweeted it. So much for long term memory…

Lesson learned.

Check out the full video by Amal below:


About Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact


  1. Widespread concave ST elevation. No reciprocal changes. ST elevation in III not greater than II. Pericarditis?

  2. This is an early repol pattern (as in pericarditis) but I think in this case we should also consider osborn waves due to the relative hypothermia. What was the patients’ temperature at the moment this ecg was recorded?

  3. I would lean more towards pericarditis as the T to P segment has a slight downward slope to it, which is found in 80% of pericarditis ECGs. This is called Spodick’s sign.

    • cheers for spotting spodick’s sign -- another thing i missed

    • Spodick’s sign is 80% sens but what is its specificity? and it can be annoying if in the am everyone points there finger at you and asking why you did not call in the cath lab? whats is most important is not the pericarditis you can diagnose but its the MI that you might miss. I have seen a number of cases of myocarditis that i could not differentiate from AMI. \

      • I think the operating characteristices of ECG findings aren’t as good as we think, but the overall, “put it all together” view of the ECG is probably pretty good. Spodick’s is probably pretty ropey as a sign, but in the context of widespread elevation and other signs of pericarditis it’s quite reassuring

  4. The ECG shows sinus rhythgm with a rate ~ 60/minute. Intervals. The axis is rightward -- almost with a left posterior hemiblock pattern … (vs simply a right axis -- so would help to know the patient’s age). Again -- we are not given the age of this patient to know if there is voltage for LVH …

    The most remarkable finding is the diffuse ST elevation in virtually all leads except lead aVR. ST segments are upward concavity (= “smiley” ), with J-point notching in several leads. The amount of ST elevation is marked. ST elevation in lead I is greater than lead III …. Overall -- the pattern is clearly most suggestive of acute pericarditis. That said -- there are a couple of things that bother me: i) the right axis (almost LPHB pattern) -- which is more than for a normal variant; ii) Minimal PR depression (perhaps a tad in aVF and V3 -- and no PR elevation in aVR (I’d really like to see PR depression in several leads with PR elevation in aVR for pericarditis); iii) T waves are a bit more peaked in several leads than is normally seen with either early repolarization or acute pericarditis (could these be hyperacute?); and iv) in addition to ST elevatiion in lead aVL -- there is sharp T wave downslope and T inversion in this lead (a bit unusual for normal variant or acute pericarditis … ).

    Knowing the age of the patient -- more on the history -- past history -- AND the nature of the chest pain would really help clinically. I suspect this is probably all baseline early repolarization with acute pericarditis on top of it -- BUT -- you CAN get an acute STEMI together WITH acute pericarditis (!!!) -- so given my reservations, I’m not yet convinced we are not seeing that …. Alas, I don’t think anyone can know for sure without more info ….. A baseline ECG -- and serial ECGs would help. I would definitely NOT activate the cath lab at this point (!) -- and this is all probably acute pericarditis -- but MORE INFO is needed (in my opinion) in order to be as sure as I would like. VERY INTERESTING TRACING.

    • Thanks for the detailed comments.

      The patient was mid 40s, no medical history of note and the pain was described as sudden onset about 9 hours prior to attendance. Pain was worse lying flat but otherwise not especially typical of pericarditis. I did ring cardiology thinking it was pericardititis but not willing to call it on my own at 4am. They agreed. No effusion on echo.

      • @Andy- THANKS for the additional information. I’m assuming no “telltale” pericardial friction rub was heard … The history of the patient being 40 without prior cardiac history and with at least some element of positional pain (worse supine) are all factors supporting a diagnosis of acute pericarditis. I think in your shoes I would also call cardiology at 4am saying “I’m pretty sure this is acute pericarditis” but I wanted you to BE AWARE of the case (since I hate to retrospectively get second-guessed). My other point simply being that acute pericarditis on rare occasions can occur superimposed on acute MI …. though that clearly does NOT seem to be what is happening in this case. I would be curious as to what this patient’s baseline ECG looked like (great if a tracing exists from before -- but also something to get AFTER the acute pericarditis resolves) given how truly peaked those T waves are …. Is that all part of a preexisting early repol variant -- with this episode of acute pericarditis superimposed on that? GREAT case!

  5. Thanks Andy. I posted a similar pericarditis case a while back and got a lot if people thinking it was a missed MI -- in an 18 yo with rheumatic fever!

    My favourite dumbass sign for pericarditis is on your rhythm strip -- the complexes look like they are running downhill or leaning to the right. Very subjective sign , but it just looks like pericarditis ,

    Did the ECHO show any effusion? My other recent learning is that painful pericarditis usually has a small trivial effusion. Big effusion less likely a cause for pain
    Nice work

    • @Casey -- Agree that an Echo is indicated, but most of the time the Echo will be negative with acute pericarditis. There may be a small effusion -- but that isn’t necessarily diagnostic of acute pericarditis. Pericardial “inflammation” unfortunately can’t be seen. Occasional pick-up of a large pericardial effusion might suggest something else in addition is going on (ie, malignancy, collagen vascular disease). A big clue to pericarditis in your case was the history (= an 18yo with rheumatic fever). Wish we had a bit more history in this case (beyond “chest pain for 9 hours” …). Always nice IF you can hear a pericardial friction rub that IS diagnostic.

    • I presume the “parker” sign of running downhill is another version of Spodick’s sign?

      • Yes, turns out I didn’t invent that one. In my defence I had a poor education and spend a lot of time practicing on my own…
        I did invent Parker’s point -- a patch on you lower left chest where heart sounds, breath sounds and bowel sounds can be heard without moving one’s stethoscope.
        Very useful in pre-anaesthetic clinic, especially when you tend to US everyone anyway. 😉

  6. I think it is worth being cautious with this ECG due to the abnormal features of aVL and the T-waves which tower over the QRS complexes in the precordials…

    …otherwise it looks pretty pathognomonic for pericarditis.

    It even has what Dr. Mattu recently highlighted, Spodick’s Sign.

    • If it is present in 80% of ECGs with pericarditis as Dr. Mattu says, Spodick’s Sign is something everyone should know!

      • Today I learned about Spodick’s sign ( ). I don’t feel bad about just learning this today -- since even Dr. Mattu admits to not being aware of this sign until very recently. I fully agree with Dr. Mattu that David Spodick is THE AUTHORITY on acute pericarditis (as he has been for years). Screen shot that I took from Dr. Mattu’s excellent 10-minute video on Pericarditis is at: -- That said -- while I fully agree that Spodick’s sign (or the “parker” sign of running downhill) is fascinating -- is present in this case (esp. in the lead II rhythm strip) -- and is likely to be helpful as an additional finding to look at -- I view it as I view PR depression (which Amal Mattu spoke similarly on in the video) -- namely GREAT if PR depression and Spodick’s sign are present -- SUPPORTIVE of the diagnosis of Acute Pericarditis when the clinical history and other ECG findings are suggestive -- but (in my opinion) should definitely not be relied upon by themselves given some shade of subjectivity in their assessment (and I BET a lot of variation in how interpreters less expert than David Spodick or Amal Mattu) will assess this sign. It can get tricky when there is baseline wander either up or down (as there often is) -- or artifact -- or tachycardia. All that said -- this tracing IS a beautiful manifestation of a positive Spodick sign!

  7. david barounis says:

    A bedside echo in the ED on any patient in whom you are concerned about BER vs AMI or even pericarditis is the way to go. If cardiology is not available immediately slap on the echo probe and take a look for regional wall motion abnormalities. Also it is important to note that many Anterior STEMI’s will not have reciprocal change and therefore can be blown off as BER because there is no STD seen elsewhere on the EKG, however up to 50% of Anterior Wall STEMI’s may lack reciprocal change. SO get an echo if you are ever unsure about the EKG if it is an anterior wall MI you will be able to see regional wall motion abnormalities.

    Sasaki et al. Relation of ST-Segment Changes in inferior Leads During Anterior Wall Acute Myocardial INfarction to Length and Occlusion Site of the Left Anterior Descending Coronary Artery. Am J Cardiol 2001; 87:1340-1345.

    • Hi David.

      Bedside echo definitely useful -- our cardiology fellows bring their echo with them to out ED for most of the emergent consults we call them for. Unfortunately I don’t think I have the skills (or indeed even the probe!) to accurately call a RWMA with confidence. Definitely within our scope of practice, but takes some training.

      • @David -- Your points are good ones (!) -- but as Andy says, a lot depends on the skill of the echocardiographer. Clearly -- a totally normal echo (no regional wall abnormality) on a patient with anterior changes that look like early repolarization is comforting. However, if one is really concerned about either the history or ECG -- it may be more difficult to send that patient home if a non-expert is the one doing the echo … As to pericarditis -- definitely indicated to do a stat Echo, as you may see a telltale pericardial effusion. But -- a normal echo doesn’t rule out acute pericarditis.

  8. Thanks Andy very useful case!!!!! I watched an Amal Mattu EKG case on differential diagnosis between STEMI and Pericarditis some time ago and thanks to your post i put on practice his teaching making differential diagnosis (PR depression, Spodick’s sign, concave ST elevation)!!!!!!!!!

  9. Thanks for this Andy, and the useful discussion. I was investigating chance of percarditis with normal ecg and normal troponins, and this is the most helpful answer so far!

    Thank you!

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