Fatal Disease Causing Secondary Pericarditis

A 74-year-old man complaining of chest pain exacerbated by inspiration and cough was referred to the cardiology department at our hospital. The chest pain initially occurred after lifting heavy luggage in the 1 week before and gradually spread thereafter. ECG shows widespread concave (“saddleback”) ST-segment elevation with PR-segment depression, suggesting acute pericarditis (Figure A). Moreover, Spodick’s sign with specificity for acute pericarditis was observed (Figure B).¹ His C-reactive protein level was markedly increased without elevation of serum creatine phosphokinase or cardiac troponin T. Echocardiography showed no wall motion abnormalities. Pericarditis was diagnosed from these findings with the pericardial irritation symptoms. However, chest computed tomography (CT) showed dilation of the ascending aorta with pericardial effusion (Figure C). Therefore, we investigated further using contrast-enhanced CT and found Stanford type A acute aortic dissection originating from the ascending aorta without extending to the coronary ostium (Figure D, Supplementary Movie). The patient was referred to another hospital for cardiac surgery and successfully underwent ascending aortic replacement.

Figure.

ECG and computed tomography (CT) findings of pericarditis and type A aortic dissection. (A) ECG, (B) enlarged images of leads V5 and II, (C) chest CT, (D) contrast-enhanced CT.

Although type A aortic dissection is associated with a high rate of ST-T abnormalities, ST-segment elevation is relatively uncommon. Acute myocardial infarction caused by dissection extending into the coronary ostium is the most common cause of ST-segment elevation. However, ST-segment elevation due to pericarditis following a type A acute aortic dissection is rarely reported. Early diagnosis and surgery for type A aortic dissection are critical life-saving interventions. Therefore, the presence of fatal aortic dissection should be considered when evaluating the ECG of pericarditis.

IRB Information

This study was granted an exemption from requiring ethics approval by Uwajima City Hospital.

Supplementary Files

Supplementary Movie. Contrast-enhanced computed tomography.

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-22-0602

Reference

• 1.   Witting MD, Hu KM, Westreich AA, Tewelde S, Farzad A, Mattu A. Evaluation of Spodick’s sign and other electrocardiographic findings as indicators of STEMI and pericarditis. J Emerg Med 2020; 58: 562–569.