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 alternance:
QRS alternance or rarely T wave alternance.

      Electrical alternance suggests pericardial effusion.

  Low voltage (suggests pericardial effusion).





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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