The ECG changes in pericarditis are generally observed at 4 stages:

  Stage 1 : Upwardly concave ST segment elevation in all leads (except aVR); PR segment depression or elevation (PR segment deviates opposite to the polarity of P wave). At stage 1, ECG findings are very similar to those of the early repolarization.

  Stage 2 : Diffuse ST segment elevation disappears. T wave flattening may be observed.

  Stage 3 : Widespread T wave negativity: Now, the ECG may resemble extensive myocardial ischemia.

  Stage 4 : ECG either becomes normal or the negative T waves may persist.



Other ECG abnormalities that may be observed during the acute stage of pericarditis

  Sinus tachycardia

  Atrial fibrillation

  Electrical alternans: QRS alternance or rarely T wave alternance. Electrical alternans suggests pericardial effusion.

  Low voltage (suggests pericardial effusion).




In some patients with acute pericarditis, PR segment depression may give the impression of pathological q waves, at first glance. In the setting of widespread ST segment elevation of acute pericarditis, possibility of such a false diagnosis high.



References (with links to full text and sample ECGs)

  BMJ Case Rep 2013 May 24;2013.

  Intern Med 2014;53(15):1659-1663.

  Heart 2007 Sep;93(9):1063.

  Clin Cardiol 2009 Mar;32(3):115-120.

  Am Fam Physician 2002 Nov 1;66(9):1695-1702.

  Am Fam Physician 1998 Feb 15;57(4):699-704.

  Singapore Med J 2005 Nov;46(11):656-660.

  Intern Med 2001 Sep;40(9):901-904.

  Am J Crit Care 2006 Nov;15(6):626-630.




ECG 1. Upwardly concave ST segment elevation in a patient with pericarditis is seen above.

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ECG 2. In the ECG above, low voltage is seen in the limb leads of a patient with effusive pericarditis.

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ECG 3. QRS aLtE rNaNc E is seen in a patient with pericarditis and pericardial effusion.

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ECG 4. The ECG above, belongs to a 17 years old male with acute pericarditis. There is upwardly concave diffuse ST segment
elevation .

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ECG 5a. This ECG belongs to a 38 years old man with acute pericarditis. PR segment is depressed in lead II and elevated in
lead aVR .

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ECG 5b. The ECG above was recorded 12 hours later. ECG findings remain the same.

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ECG 5c. This ECG was recorded at the third day of medical therapy. PR segment elevation and depression is not seen anymore.

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ECG 6. QRS alternance in a patient with pericarditis and massive pericardial effusion.

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ECG 7. This ECG is from a patient with pericardial effusion. QRS amplitude increases and decreases : QRS alternance.

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ECG 8. The ECG above belongs to a 65 years-old woman complaining of chest pain. Her coronary angiography showed only
minimal atherosclerosis (40% stenosis) in the Cx artery. She also had leukocytosis. The ECG shows PR segment elevation in
lead aVR and ST segment elevation in lead aVR . Most of the leads show PR segment depression and ST segment depression.
Her ECG suggests pericarditis.

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ECG 9. The ECG above belongs to a 53 years-old man with pleuritic chest pain and normal coronary arteries.
His chest pain was of only 2 days duration.
Lead aVR shows PR elevation and ST depression, while most other leads show PR depression and ST elevation.
His erythrocyte sedimentation rate is elevated. The clinical and laboratory findings are compatible with acute pericarditis.

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ECG 10. The above ECG is from a 72 years-old man who had undergone mitral valve replacement 8 months ago.
It was recorded during pericarditis without effusion (2 weeks after surgical drainage of the effusion).
Widespread T wave negativity suggests pericarditis, NOT left ventricular strain.




ECG 11. The ECG above is from a 59 years-old man with bronchoalveolar lung cancer, massive pericardial effusion and
cardiac tamponade. QRS alternans is clearly seen. Urgent pericardiocentesis was performed after confirming
the pericardial effusion by ECHOcardiography (900 ml hemorrhagic fluid was drained).

The ECG above has been used with the permission of Texas Heart Institute Journal.

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Click here to go to the relevant article of the Texas Heart Institute Journal



ECG 12. The above ECG is from a 21 years-old man who complains of atypical chest pain.
ST segment depression in lead aVR and ST segment elevation in other leads suggest pericarditis.

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ECG 13. The ECG above belongs to a 47 years-old woman with pericardial effusion.
QRS alternans is best seen in lead V2.

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ECG 14. The ECG above belongs to a 36 years-old man with atypical chest pain, unrelated to exertion.
His cardiac Troponin I level was mildly elevated. Coronary angiography showed normal coronary arteries.
Widespread ST segment elevation is seen. Some leads also show PR segment depression.
The above ECG is suggests pericarditis.

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ECG 15a. The ECG above belongs to a 60 years-old man with atypical chest pain at rest.
His cardiac Troponin I level was mildly elevated. Coronary angiography showed normal coronary arteries.
Widespread ST segment elevation suggests acute myopericarditis.
Frequent atrial premature beats in the form of atrial trigeminy are also present.
Antibiotic and antiinflammatory therapy was started.

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ECG 15b. The ECG above belongs to the same patient. It was recorded 9 days after the ECG 15a.
Now, he was admitted to the Cardiology clinic with the complaint of recent-onset palpitation.
The rhythm is atrial fibrillation.
Extensive ST segment elevation persists but the amplitude is decreased when compared to the ECG 15a.
All leads (except III and aVR) show negative T waves.
Since his atrial fibrillation duration was < 24 hours, he was hospitalized for medical cardioversion.

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ECG 15c. The ECG above belongs to the same patient. It was recorded 3 hours after the ECG 15b
(2 hours after the onset of intravenous Amiodarone infusion).
Now the rhythm is sinus.
Chest leads show ST segment elevation but the amplitude is decreased when compared to the ECG 15a.
Subtle ST segment elevation is also present in leads I, II and aVL.
All leads (except III and aVR) show negative T waves.
These ECGs are typical for the evolution of ECG changes in pericarditis.

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ECG 15d. The ECG above belongs to the same patient. It was recorded 11 days after the ECG 15c.
ST elevation in chest leads is diminished.
Note that very little change has occurred in 11 days.

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ECG 15e. The ECG above belongs to the same patient. It was recorded 18 days after the ECG 15d.
Leads V2, V5 and V6 show no T wave negativity.
The amplitude of negative T waves decreased in leads V3 and V4.
ST elevation is not seen any more.
The patient had no chest pain during this stage.

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ECG 15f. The ECG above belongs to the same patient.
It was recorded approximately 5 months after the ECG 15e (6 months after the onset of pericarditis).
The patient has no chest pain. The ECG is normal.

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ECG 16. The ECG above belongs to a 34 years-old man with pleuritic chest pain and leukocytosis.
The rhythm is sinus tachycardia with PR segment depression in most leads and
PR segment elevation in lead aVR.
His symptoms, ECG findings and leukocytosis suggests the diagnosis of acute pericarditis.
PR segment deviations during pericarditis may not be evident at first glance.

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ECG 17a. The ECG above belongs to a 33 years-old man with the diagnosis of pericarditis.
Inferior and anterior leads show negative T waves.

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ECG 17b. The ECG above belongs to the same man. It was recorded 15 months after the ECG 17a.
The ECG is normal.

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ECG 18a. The ECG above belongs to a 42 years-old man with acute myopericarditis.
Inferior leads and leads V4 to V6 show ST segment elevation.
The ECG computer misinterpreted it as acute inferior wall myocardial infarction.
Cardiac Troponin I level was minimally elevated and he underwent coronary angiography.
Normal coronary arteries were observed.



ECG 18b. The ECG above belongs to the same man.
It was recorded one month after the ECG 18a.
ST segment elevation is not seen any more.
Inferior leads and leads V4 to V6 show negative T waves.
At this moment, the patient is asymptomatic.

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ECG 19a. Above is an ECG from a 74 years-old woman with normal coronary arteries.
Many leads show PR segment depression and ST segment elevation.
Lead aVR shows PR segment elevation and ST segment depression.
This ECG is compatible with acute pericarditis.

Prof. Dr. Hakan Gullu has donated the above ECG to our website.



ECG 19b. The ECG above belongs to the same patient. It was recorded 5 days after the ECG 19a.
The ECG changes in the ECG 19a are less prominent now.

Prof. Dr. Hakan Gullu has donated the above ECG to our website.




ECG 20. Above is an ECG from a 25 years-old man with atypical chest pain.
Most of the leads show PR segment depression while lead aVR shows PR segment elevation.
Most of the leads also show ST segment elevation.
At first glance, PR segment depression in leads II and aVF may seem as "pathological q waves".
His Troponin levels were above upper limit of normal. His ECHOcardiography examination was normal.
He was diagnosed as acute perimyocarditis.
This case shows that PR segment depression must not be confused with pathological q waves.

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