Case:
45 yo woman with past medical history of SLE, diabetes, and migratory arthritis who presents to the ED for evaluation of exertional chest pain for 5 days associated with shortness of breath, nausea, but no vomiting. Patient is well appearing and in no acute distress.
Initial vital signs:
Temp: 36.6 C
BP: 129/79
HR: 130 bpm
RR: 20
O2 sat: 95% room air
The initial is ECG shown below:
Click to enlarge
Computer interpretation:
Rate: 125 BPM
Sinus tachycardia
*ACUTE MI*, ST elevation, consider anterior injury
Physician Interpretation:
Rate: 125 bpm
Rhythm: Sinus rhythm
Axis: Left axis deviation
Intervals: normal
PR segment:
PR depression in leads I, II, aVL, V4-V6
PR elevation in aVR
ST segment:
<1 mm ST elevation in lead I
1 mm ST elevation in lead aVL
<1 mm ST depression in lead aVR
Additional findings: Spodick’s sign*, or downsloping of the TP segment, most notably visualized in leads I and aVL. Also noted in lead II, however less prominent in lead II
*Spodick’s Sign:
The downsloping of the TP segment, best visualized in the lateral precordial leads and lead II, was first described and coined “Spodick’s sign” by Dr. David Spodick in 1974. An example is shown in the image below:
Image from: https://litfl.com/spodick-sign/
In acute pericarditis, common ECG findings include:
sinus tachycardia (secondary to pain, effusion and/or concomitant myocarditis)
widespread concave ST elevation with PR depression
reciprocal ST depression and PR elevation in lead aVR (±V1)
While PR depression is more common in acute pericarditis, it can be seen in both acute pericarditis and acute coronary syndrome (ACS), and its presence should not be used alone to differentiate these two entities. The presence of PR depression and Spodick’s sign is more suggestive of pericarditis when compared to its counterpart, a STEMI, and can aid in differentiating these two conditions.
Spodick’s sign was evaluated in a recent retrospective analysis comparing cases of STEMI to pericarditis. All of the selected ECGs were reviewed for the presence or absence of Spodick’s sign. Of 165 patients who met criteria for STEMI and 42 for that of pericarditis, it was noted that Spodick’s sign was present in 5% of STEMI cases and 29% of pericarditis cases. However, other “classic” findings such as ST depression and the absence of PR depression had the greatest odds ratio for STEMI. The findings from this analysis are shown in the figure below:
Image from: liftl.com/spodick-sign/
When attempting to distinguish pericarditis from STEMI, ask the following questions:
Is there ST depression in a lead other than aVR or V1? This is more suggestive of STEMI
Is there ST elevation greater in lead III than in lead II? This is more suggestive of STEMI
Is there horizontal or convex upward ST elevation? This is more suggestive of STEMI
Is there PR depression in multiple leads? This is more suggestive of pericarditis
After this, the finding of additional features, such as Spodick’s sign, can be used to further support the diagnosis of pericarditis.
What happened next?
Ultimately, a CODE STEMI was called and the patient received Aspirin 325 mg and sublingual Nitroglycerin given findings of ST elevation in lateral leads. Cardiology evaluated the patient and agreed that this was likely pericarditis as opposed to STEMI. Initial troponin was negative. The patient’s repeat ECG is shown below, which was largely unchanged.
Click to enlarge
Bedside cardiac ultrasound showed no regional wall abnormalities and no pericardial effusion. The patient received ibuprofen and colchicine for treatment of her pericarditis, and she was admitted to the general medical floor, where her symptoms continued to improve.
Heart of the Matter:
While Spodick’s sign is an additional sign that can be used in trying to distinguish acute pericarditis from acute coronary syndrome, it should not be used in isolation. In fact, Spodick’s sign can be seen in acute STEMI. Use this sign in conjunction with findings of widespread concave ST elevation paired with PR depression. Cardiology consultation should be made in cases where the diagnosis may be unclear.
For more reading:
Life in the Fast Lane: https://litfl.com/spodick-sign/
EM Docs: http://www.emdocs.net/ecg-pointers-pericarditis/
Resources:
Chaubey, V. et al., Spodick’s Sign: A Helpful Electrocardiographic Clue to the Diagnosis of Acute Pericarditis. The Permanente Journal. 2014. 24626086
Witting, M. et al., Evaluation of Spodick's Sign and Other Electrocardiographic Findings as Indicators of STEMI and Pericarditis. J Emerg Med. 2020. 32222321
Written by:
Jennifer Lee, MD - PGY 3
Cook County Health
Twitter: @JennLeeMD
Rayyan Kadi, MD - PGY 3
Cook County Health
Twitter: @RayyanKadi
Reviewed by:
Tarlan Hedayati, MD
Chair of Education
Department of Emergency Medicine
Cook County Health
Twitter: @HedayatiMD