CME INDIA Case Presentation by Dr Ashutosh Chandan Dubey (Dr Strange), DNB (Med), Renukut, UP.

CME INDIA Case Study:

Age-16-year, male, Presented with Chest pain. Trop-T positive. CKMB-raised. Normal-2D Echo, no RWMA and EF-62% (on 23/12/2020).

16-year-old boy with Chest Pain - ECG

16-year-old boy with chest pain - ECG

ECG on 25/12/2020

CME INDIA Discussion

Dr Monica Gupta, Varanasi: Fever? Sob?

Dr Ashutosh C Dubey: No.

Dr Venkatesh Molio, Maregoan, Goa: Acute myopericarditis is the first possibility.

Dr Anupam, DM Card Medica, Ranchi: ECG changes are s/o pericarditis.

Dr Himalaya Jha, Consultant Physician, CMO-CGHS, Ranchi: Down sloping TP segment is found in 80 percent of patient of Acute pericarditis. Best seen in lead 2 and v5, V6

16-year-old boy with chest pain - ECG
(Illustration by Dr Himalaya Jha)

Dr Prashant Waichal Mahar, Akola: We will also get PR segment depression

Dr Himalaya Jha: Concave ST elevation in infero -lateral leads with ST depression in aVR.

PR segment depression in lead ll, lll, avF and v 4, v 5 and v6.

– PR segment elevation in aVR. Pericarditis

Dr Ashutosh Chandan Dubey: A 16-year-old male with chest pain, it was retrosternal chest pain, deep seated… Non-radiating, not related to respiration, no palpitation, cough or fever, no diaphoresis.

raised CK MB, 2D ECHO showing No RWMA, LVEF of 62%.ECG 12 leads showing generalized ST Elevation with concavity upwards. Thyroid profile and rest Test were normal. ECG was repeated after 1 month showing T wave inversion.

Dr D P Khaitan, President CCDSI, Gaya: SPODICK’S SIGN – down sloping of TP segment is present in lead 11 in this case. Whenever there is evidence of acute pericarditis the presence of this sign should be searched in lead II (best seen in this lead) + lateral leads.

Findings PR and ST segments typically points in opposite directions (PR sign) in limb leads and chest leads V4 and depressed ST segment is seen in aVR and V1. T is mainly positive. The frontal plane ST segment axis is directed to +60 Spodick sign being positive

Dr Satish Kumar, Chairman, CSI-Jharkhand:

16-yr-old-chest-pain-ECG

If associated Myocarditis, Tachycardia might obscure Spodick Sign to appear. This is probably what is happening to my patient today most likely having Viral Myocarditis (Classical History and Echo findings)


CME INDIA Learning Points

By Dr D P Khaitan, MD (Medicine), FCGP (IND), FIAMS (Medicine), FICP, President CCDSI

Who was Dr David H Spodick, MD (1927 to 2019)?

  • One should be intellectually rational. Dr David H Spodick himself was a worshipper of such an approach in his life and of great repute, researcher and teacher in the world of cardiology. He had contributed so many research papers pericardial diseases.
  • This Spodick Sign in acute pericarditis is also his intellectual gift to the medical science. It is present in about 80% of cases.
  • This legendary researcher Dr David H Spodick died at age of 91 on May 19, 2019. He was a fatherly figure to many generations of cardiologists across the world. He was the Emeritus Professor of Medicine at the university of Massachusetts Medical school.

Spodick’s sign and acute pericarditis

  • This sign refers to concave JT-segment elevation TP-segment, best seen in lead II and left lateral highlighted by the red arrow in lead II

Spodick's sign
(Illustration by Dr Himalaya Jha)

  • In acute pericarditis, there is a potential difference across the transmyocaridum of the isoelectric TP segment. This becomes essential to understand the pathophysiological changes being operated in acute pericarditis

Pathophysiological changes in acute pericarditis leading to Spodick’s sign

Step 1: A concept of normal polarized state – TP segment.

After the completion of the phases of ventricular depolarization and repolarisation, there is a segment having isoelectric line (TP segment) having no potential difference across the cardiac membrane. During this phase, the inward and outward current are equal with the resetting of the cardiac potential to the normal brought about by Na+ – K+ adenosine triphosphate pump. The TP segment is said to be in polarized state with no potential difference. The entire event is illustrated by the following sketch:

A concept of normal polarized state - TP segment

Step 2: Acute Pericarditis

The pericardium is a fibrous sac surrounding the heart consisting of two layers: a thin visceral layer attached to the myocardium and as a thicker outer pericardial layer. Acute Pericarditis occurs when these layers are inflamed, extending the flame of inflammation to some extent to the underneath myocardium of atria and ventricles both throughout. These creates potential difference across the myocardium even during the TP segment. Now the TP segment is not in a polarized state. The entire event is illustrated-fig 1.3:

 Acute Pericarditis

Step 3: The basis of the Spodick’s sign is the potential difference in between epicardium and endocardium creating the epicardial injury (brought about by the pathological changes of the acute pericarditis).

 * During the phase 4 of the ventricular action potential, there is a genesis of epicardial injury and as a result of which the vector is directed from epicardium to endocardium resulting in a slight down going TP segment depression, as illustrated in Fig-1.4:

Phase 4 of the ventricular action potential

  • The atrial repolarisation waves come somewhat earlier resulting in an apparent inverted PTa wave over the PR segment, manifested as PR depression (normally very small PTa wave is not visible on ECG due to its hiding under QRS complex).
  • There is an apparent J point and ST segment elevation, being evident due to the down slowing TP segment.

Step 4: Due to the vectorial direction , the corresponding changes during the segment and ST and TP are best observed lead II and left precordial leads. Since atrial and ventricular myocardium are in opposite direction , with acute pericarditis the PR and ST segments point in opposite direction (PR – ST segment discordance sign) with the PR being elevated by more than 0.8 mm for so in lead aVR with the ST usually being slightly depressed in that lead.

J point and ST segment elevation

Step 5: Whenever there is loss of TP segment acute pericarditis, one cannot see the slight down sloping of the TP segment.

Concluding Remark

Spodick’s sign is a helpful Electrocardiographic Clue to the diagnosis of Acute Pericarditis during its stage 1.


CME INDIA Tail Piece:

Nice write up by Andrew R Houghton, Cardiologist, UK. Author of the Making Sense series of cardiology textbooks, and a faculty member at Medmastery.

Shared by Dr R Rajasekar, Kumbakonam:

Spodick’s sign: Downsloping TP segment in pericarditis

  • ⚛️An eponymous sign in ECG interpretation — Spodick’s sign, which is used in the ECG diagnosis of pericarditis.
  • ✴️Spodick’s sign refers to concave JT-segment elevation followed by a slight downsloping of the TP-segment. This slight downsloping in highlighted by the red arrows in the figure below, which shows ECG lead II in a patient with acute pericarditis.
  • ☸️Spodick’s sign: Downsloping of the TP segment…
  • Spodick’s sign is reported to be present in around 80% of cases of acute pericarditis, although the reliability of the sign as a diagnostic indicator has been questioned by some.
  • ✳️Spodick’s sign is named for David H. Spodick, who is Professor of Medicine Emeritus at the University of Massachusetts Medical School. We have some of his publications of ECG on pericarditis.

Reference:

1. LeoSchamroth and INTRODUCTION TO ELECTROCARDIOGRAPHY (Eighth Adapted Edition), P 115-125

2. Spodick’s Sign : A Helpful Electrocardiographic Clue to the Diagnosis of Acute Pericarditis, March 2014 : The Premanente Journal 18(1):e122, Author – Vinod Kumar Chaubey, Baystate Medical center, Lovely chhabra, Westchester Medical center, Website – www.researchgate.net>publication


Discover CME INDIA: