1. What was the diagnosis.
This is almost certainly pericarditis. The patient is young, the history not classical for IHD at this age and the ECG is consistent with that diagnosis.

2. Describe the features on the ECG that led you to the diagnosis. Is this a classical example?
There are saddle shaped ST changes in the anterior leads. There are NO reciprocal changes seen. There is a small amount of PR depression (commonly seen with pericarditis). The T waves are less than 25% the height of the QRS complexes, in an MI the T waves get bigger, longer and symmetrical (hyper acute T waves).

You might also question whether this reflects high take off in a young person (presence of a J wave, early transition etc. ) However, this was subsequently rules out due to the transient nature of the changes.

It is not a classical example owing to the distribution of the changes. Normally these are most marked in leads looking at the apex (II, V5, V6).

3. This patient was initially treated as an acute coronary syndrome with aspirin, beta blockers, fragmin and clopidogrel. Comment on the treatment.

Well, it is probably not a disaster. However, the fragmin and the clopidogrel were probably not needed and may lead to bleeding complications.


The patient was further investigated with serial cardiac markers (normal), repeat ECGs (resolving), and an ECHO (normal). He made a complete recovery.

Further reading

Pericarditis and Tamponade
http://www.emedicine.com/EMERG/topic412.htm

ECG changes
http://www.aafp.org/afp/980215ap/marinell.html