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Jurnal Kedokteran dan Kesehatan Indonesia
Indonesian Journal of Medicine and Health
Journal homepage : https://journal.uii.ac.id/JKKI
ABSTRACT
ARTICLE INFO
Regional pericarditis with reciprocal ECG changes mimicking inferior
ST-elevation myocardial infarction (STEMI): a case report
Gilang Mauladi Rahman*1, Mochammad Yusuf Alsagaff2
1Cardiology and Vascular Medicine Resident, Faculty of Medicine, Universitas Airlangga - dr. Soetomo General
Hospital, Surabaya, Indonesia
2Cardiologist, Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga – dr.
Soetomo General Hospital - Airlangga University Hospital, Surabaya, Indonesia
*Corresponding author:
gilangmauladirahman@gmail.com
Keywords:
regional,
pericarditis,
reciprocal,
changes,
mimicking,
STEMI
History:
Received: March 19, 2019
Accepted: March 10, 2020
Online: April 30, 2020
DOI: 10.20885/JKKI.Vol11.Iss1.art13
Case Report
Copyright @2020 Authors.
This is an open access article
distributed under the terms
of the Creative Commons At-
tribution-NonCommercial 4.0
International Licence (http://
creativecommons.org/licences/
by-nc/4.0/).
85
Acute pericarditis is generally presented with a chest pain and a diffuse
ST-segment elevation in ECG. Focal ST-segment elevation due to localised
ST-elevation myocardial infarction (STEMI). A case in this study was a
30-year-old man in emergency room as a surgery resident experiencing
recently acute typical chest pain. He had a history of smoking without
other cardiovascular disease risk factors. ECG immediately was conducted,
and it revealed ST-segment elevation in an inferior lead with reciprocal
ST-segment depression in aVL, which was typical for an inferior STEMI.
Primary PCI was conducted, and it surprisingly revealed a normal coronary
artery. Serial serum cardiac biomarkers found a normal cardiac troponin-I
examinations. We treated the patient as a suspect of coronary spasm with
calcium-channel blockers and nitrates. After three days of hospitalization,
the patient was discharged from the hospital, and he planned to get
cardiac magnetic resonance (CMR). The CMR was conducted after seven
days of the discharge, and it revealed a loculated pericardial effusion
leading to regional pericarditis. The patient was treated with empirical
NSAIDs for three weeks. Clinical and echocardiographic evaluation after
the treatment showed an excellent result. A presence of focal ST-segment
elevation with reciprocal ST-segment depression was generally consistent
with the STEMI, but this case was an exception. Although rare, regional
pericarditis can be a differential diagnosis in a patient with acute chest
pain with a focal ST-segment elevation.
Perikarditis akut umumnya datang dengan presentasi klinis nyeri dada dan elevasi segmen-ST difus pada
gambaran STEMI. Kasus: laki-laki berusia 30 tahun seorang residen bedah yang sedang bertugas di
Instalasi Gawat Darurat (IGD) datang dengan keluhan nyeri dada tipikal akut yang baru saja dirasakannya.
Dia memiliki riwayat merokok, tanpa faktor risiko penyakit kardiovaskuler lainnya. Pemeriksaan EKG
segera dilakukan dan menunjukkan suatu elevasi segmen-ST pada lead inferior dengan depresi segmen-
ST resiprokal di lead aVL yang khas untuk STEMI inferior. PCI primer segera dilakukan dan secara
mengejutkan menunjukkan hasil yang normal. Pemeriksaan biomarker troponin-I menunjukkan hasil
JKKI 2020;11(1):85-91
86
pasien sebagai suspek spasme koroner dengan
terapi calcium-channel blockers dan nitrat. Setelah
tiga hari perawatan, pasien keluar dari rumah sakit
dan direncanakan untuk menjalani pemeriksaan
MRI jantung. MRI jantung dilakukan tujuh hari
kemudian dan didapatkan hasil efusi perikard
terlokulasi mengarah pada perikarditis regional.
non steroid (OAINS) empiris selama tiga minggu.
menujukkan hasil yang sangat baik. Adanya elevasi
segmen-ST fokal disertai dengan depresi segmen-ST
resiprokal biasanya mengarah ke STEMI, namun
kasus ini merupakan pengecualian. Meskipun
jarang, perikarditis regional dapat menjadi
diagnosis banding pada pasien dengan nyeri dada
akut disertai dengan elevasi segmen-ST fokal.
INTRODUCTION
pericardium generally presented with chest
pain, pericardial friction rubs, and typical ECG
changes. It is diagnosed in approximately 0.1%
hospitalised patients with chest pain.
1
The most
common aetiology of pericarditis in developed
countries is viruses, whereas tuberculosis is the
most frequent cause in developing countries.
2
Pericarditis is the most common form of
pericardial diseases which typically affect young
and middle-aged people, and it is usually suffered
by men of 20 to 50 year old.1
A clinical diagnosis of acute pericarditis can be
conducted based on two of the following criteria:
a) pericardial chest pain, b) pericardial friction
rub, c) typical ECG changes, and d) pericardial
effusion (new or worsening).
2
A chest pain of
acute pericarditis is usually sudden in onset,
pleurisy, and felt in retrosternal. An audible
pericardial friction rub, that presents in 85%
pericardial friction rub is a high-pitched, scratchy
or squeaky sound heard at the left sternal border.
Typical ECG changes in acute pericarditis include
wide-spread upward concave ST-segment
elevation and PR-segment depression. The
echocardiogram (TTE) supports the diagnosis
and guides further management.2,3
ECG changes related to pericardial
of patients with acute pericarditis. Typical
ECG changes include classic diffuse concave
upward ST-segment elevation and PR segment
depression without T wave inversion. In contrast,
regionally distributed convex ST-segment
elevation with or without pathologic Q waves
and reciprocal ECG changes commonly occur
in STEMI.
1,4
Although diffused ST-segment
elevation is typical for pericarditis, focal ST-
of pericardium in regional pericarditis can
resemble the STEMI.
5
This case report presents
a case of regional pericarditis with clinical and
electrocardiographic presentations that are
nearly indistinguishable to the STEMI.
CASE REPORT
A 30-year-old man in the emergency room
as a surgery resident experienced acute typical
chest pain (2 hours of onset) and became
worsened until he took a medical evaluation.
He had a history of smoking without other
cardiovascular risk factors. There was no history
disease, or malignancy. His vital signs were stable,
and there was no abnormality of his physical
examination. ECG examination immediately
was conducted, and it revealed ST-segment
elevation in the inferior lead with reciprocal
ST-segment depression in aVL (Figure1). Then
a diagnosis of interior STEMI had been made.
A primary percutaneous coronary intervention
(PCI) immediately was conducted as a primary
PCI-capable hospital. Before the PCI, a diagnostic
coronary angiography (DCA) was routinely
conducted to evaluate his coronary anatomy and
surprisingly revealed a right dominant normal
coronary artery without any supporting evidence
of coronary obstruction (Figure 2), so the PCI was
not conducted. Serial serum cardiac biomarkers
found a normal cardiac troponin-I level (<0.001
serial examinations. The researchers began
conservative therapies with calcium-channel
blockers (diltiazem slow release 200 mg per
Rahman and Alsagaff. Regional pericarditis with...
87
day) and nitrates (isosorbide dinitrate 5 mg
twice a day) as a suspect of coronary spasm.
After three days of hospitalisation, the patient
was discharged and was planned to perform
cardiac magnetic resonance (CMR) imaging.
The CMR was conducted seven days after
the discharge, and it revealed a normal left
ventricle function and dimension. Pericardial
effusion was loculated at the left apical and
right free wall without pericardial thickening
(Figure 3A). T2 weighted images showed no
increased signal intensity in the myocardium
but marked pericardial enhancement (Figure
3B). Early gadolinium enhancement image
showed no thrombus detected as intracavity.
Late gadolinium enhancement image showed
no hyperenhancement in the myocardium . The
summary of the CMR examination presumed that
the patient experienced regional pericarditis. The
patient was treated with empirical non-steroidal
mg three times a day for three weeks. Clinical
and TTE evaluation was conducted after the
treatment revealed a preserved left and right
ventricle function without sequels of the last
illness. The patient was asymptomatic without
evidence of pericardial effusion or constrictive
pericarditis on TTE.
Figure 1. 12-Lead ECG was at the Presentation. There was ST-segment elevation
in inferior lead (II,III, and aVF) with reciprocal ST-segment depression in aVL,
presumed as Interior STEMI.
Figure 2. These was Diagnostic Coronary Angiography (DCA) images. Right
(left panel) & left coronary angiography (right panel) was presented. There
were normal epicardial arteries, including right coronary artery (RCA), left
main coronary arteries (LMCA), Left Anterior Descendens (LAD), and Left
JKKI 2020;11(1):85-91
88
DISCUSSION
According to the European Society of
Cardiology (ESC) guidelines, a working diagnosis
of STEMI based on symptoms is consistent
with myocardial ischemia (i.e. persistent chest
pain) and ST-segment elevation on ECG. At a
Percutaneous Coronary Intervention (PCI)
capable centre, a primary PCI is recommended
in all STEMI patients with <12 hours of onset
and persistent ST-segment elevation, and it must
be organized immediately with door to wire
crossing time less than 60 minutes.6
The working diagnosis of inferior STEMI was
made based on typical chest pain and ST-segment
elevation on inferior lead, with reciprocal ST-
segment depression in the lateral lead . As a PCI
capable hospital, the researchers immediately
conducted the primary PCI. Normal coronary
arteries on DCA and a normal serial troponin-I
level made the diagnosis of STEMI unlikely. Thus,
The patient was treated as a suspect of coronary
spasm.
The ST-segment elevation of inferior (lead II,
III, & aVF) with lateral (lead aVL) ST-segment
depression (reciprocal changes) on ECG was
highly sensitive for coronary occlusion and
7
Diffuse ST-segment elevation is typical of classic
pericarditis, but in uncommon entity especially
regional pericarditis, there is a focal ST-segment
elevation arising from localised irritation of
the pericardium. That focal quality made the
regional pericarditis particularly challenging to
differentiate from the STEMI.
8
A lack of reciprocal
ECG changes tended to suggest it as regional
pericarditis.
9
The regional pericarditis presented
a further challenge to diagnose due to a paucity
of published diagnostic criteria. Furthermore,
this condition.10 Therefore, the clinical and ECG
In this case, the patient experienced a typical
chest pain and ST-segment elevation in the inferior
lead with reciprocal ST-segment depression in
aVL on ECG that was consistent with an inferior
STEMI. Nevertheless, an alternative diagnosis
should be considered when coronary arteries
and troponin-I level were normal. Therefore, a
diagnostic evaluation with an advanced imaging
modality was conducted.
Recent advances in multimodality non-
invasive cardiac imaging have had an essential
role to diagnose patients with suspected
pericarditis, especially in challenging diagnoses.
Critical roles of Transthoracic Echocardiogram
in diagnosing pericardial pathology, and
then a detailed anatomic characterisation
Figure 3. These were Cardiac Magnetic Resonance (CMR) images. Functional
Left ventricular function and dimension were normal.(A) Pericardial effusion
was loculated in left ventricle apical wall and right ventricle free wall without
pericardial thickening.(B) T2 weighted images showed no increased signal
density, but marked pericardial enhancement.
A B
Rahman and Alsagaff. Regional pericarditis with...
89
of the pericardium provided by Cardiac
Magnetic Resonance has aided to determine
aetiology of pericardial pathology.
10
Although
of imaging modalities in pericarditis, CMR has
ability to improve lesion visualisation and tissue
characterisation of the pericardium. T2-weighted
CMR imaging is superior for visualising oedema
enhanced CMR studies are useful in depicting
11
In this case, CMR was performed seven
days after discharge, and it revealed a normal
functional left ventricle function and dimension
with normal ventricular wall motion. Pericardial
effusion noted loculated at apical of the left
ventricle and right ventricle free wall, without
pericardial thickening (Figure 3.A). T2 weighted
images showed no increased signal intensity
in the myocardium but marked pericardial
enhancement (Figure 3.B). The summary of
the CMR examination tended to consider it as
regional pericarditis.
Pericarditis could be results of the local
pathology in the pericardium or systemic
disease. The common cause of pericardial
pathology includes viral infection, tuberculosis,
infarction. Systemic disease, such as malignancy,
and uremic state in chronic kidney disease, can
precipitate acute pericarditis. Other causes
include aortic dissection, pharmacologic
agents (e.g. hydralazine, isoniazid), radiation
treatment, and trauma.1,3 In most patients, the
cause of acute pericarditis is considered to be
is inconclusive.
3
Regional pericarditis has
been described at only a few publications
and remained relatively unknown and under-
diagnosed condition. Regional pericarditis can
occur at the various setting with the majority of
reported cases are associated with myocardial
infarction and trans-mural myocardial necrosis.12
In this case, the patient had no history or
clinical suspicion of tuberculosis, systemic
the normal coronary arteries and normal serial
troponin-I, the suspicion of myocardial infarction
associated pericarditis became unlikely. We did
for the clinical diagnosis of regional pericarditis
in this patient. As a result, the aetiology of
pericarditis, in this case, remained idiopathic.
According to ESC Guidelines, aspirin or
line therapy for acute pericarditis. If the clinical
diagnosis has been conducted, symptomatic
treatment with aspirin or NSAIDs should be
initiated. Aspirin 750-1000 mg three times a
day or ibuprofen in a dose of 600 to 800 mg
orally three times a day were preferred for the
patient with discontinuation if there was no
longer pain after two weeks. Colchicine could be
added if the patient had no response to empirical
NSAIDs. Colchicine was recommended at low,
weight-adjusted doses to improve the response
to medical therapy and to prevent recurrences.
Colchicine was administered as a 2 to 3 mg oral
loading dose followed by 0.5 mg once a day
(bodyweight <70 kg) or twice a day (bodyweight
> 70 kg) for three months.5
Patients with acute idiopathic or viral
pericarditis generally have an excellent long-
term prognosis. Recurrences are the most
common complication following pericarditis.
Immune mechanisms appear to be of primary
importance in the majority of cases.
13
Cardiac
tamponade rarely occurs in patients with acute
idiopathic pericarditis and is more common in
such as malignancy, tuberculosis or bacterial
infection. Constrictive pericarditis may occur
in about 1% of patients with acute idiopathic
pericarditis and is also more common in patients
14
In this case, the researchers initially treated
the patient with calcium-channel blockers
(diltiazem slow release 200 mg a day) and
nitrates (isosorbide dinitrate 5 mg twice a day)
as a suspect of coronary artery spasm. When the
NSAIDs was started. The response to the therapy
was excellent. Clinical and TTE evaluation was
JKKI 2020;11(1):85-91
90
conducted after treatment, and it revealed a
preserved left ventricle and right ventricle
function without sequel of the last illness.
CONCLUSION
The researchers reported an exceptional case
of regional pericarditis with typical chest pain
and focal pattern of ST elevation with reciprocal
ECG changes which was initially misdiagnosed to
STEMI. At that time, as the PCI capable hospital,
a primary PCI was immediately conducted. An
alternative diagnosis was considered when
the DCA before primary PCI revealed a normal
coronary artery and troponin-I. CMR was also
uncommon form of the pericardial disease, the
regional pericarditis. After the clinical diagnosis
had been organized, the patient was treated
drugs (NSAIDs) for three weeks, and the result
was excellent. The advanced cardiac imaging
modalities such as TTE and CMR may be required
to evaluate the abnormality of the pericardium
in the suspicion of regional pericarditis.
CONFLICT OF INTEREST
The authors declared that there was no
this article.
ACKNOWLEDGEMENT
The authors would like to express deep
gratitude to doctor Mochammad Yusuf Alssagaff,
a cardiologist and a mentor who provided advice,
for this case report.
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