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PR Segment—A Neglected Electrocardiogram Profile in Acute Chest Pain

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A patient in their 40s with no medical history presented to the emergency department with chest pain of a 4-hour duration. The pain was substernal, intensified by lying supine, and relieved by leaning forward. On admission, the patient’s vital signs included a temperature of 37.3 °C, blood pressure of 147/93 mm Hg, pulse rate of 103 beats/min, and respiratory rate of 20 breaths/min. The results of the rest of the physical examination were normal. The troponin I and N-terminal pro–brain natriuretic peptide levels were normal. A transthoracic echocardiogram demonstrated normal ventricular ejection fraction, chamber size, and motion and the absence of pericardial effusion. The 12-lead electrocardiogram (ECG) at admission is shown in the Figure, A.

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Acute pericarditis is a common disease in patients experiencing chest pain, accounting for approximately 5% of emergency department presentations with chest pain.3 The condition may develop into cardiac tamponade, with which the in-hospital mortality rate was 1.1%.3 Therefore, the identification of AP is crucial in medical practice. The ECG is useful in the diagnosis of AP, with changes occurring in about 90% of patients.4 Changes on ECG are classically divided into 4 stages.4 Stage I typically occurs during chest pain and is mainly characterized by multilead ST elevations and PR depression. The PR segment represents the atrial repolarization. The depression of the PR segment, which is very specific to AP and denotes subepicardial atrial injury, occurs in all leads except aVR and usually V1, in which PR elevation is the usual finding.4 This stage may last up to 2 weeks after initial symptoms. However, this stage lasted less than 1 week in the present case, which might have been because of aggressive anti-inflammatory treatment. Stage II is represented by the fall of the ST segment to baseline and flattening of T waves. Stage III is characterized by the inversion of T waves in almost all leads (opposite to the original direction of the ST segment). Gradual resolution of T-wave inversion occurs in stage IV. Although AP exhibits characteristic changes in stage I on ECG, 2 conditions that are commonly confused with AP include STEMI and early repolarization.

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Article Information

Corresponding Author: Yangyi Lin, MD, Department of Pulmonary Vascular Disease, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing, China (dr.linyangyi@outlook.com).

Published Online: October 3, 2022. doi:10.1001/jamainternmed.2022.4037

Conflict of Interest Disclosures: None reported.

References
1.
Alzand  BS , Gorgels  AP .  Combined anterior and inferior ST-segment elevation: electrocardiographic differentiation between right coronary artery occlusion with predominant right ventricular infarction and distal left anterior descending branch occlusion.   J Electrocardiol. 2011;44(3):383-388. doi:10.1016/j.jelectrocard.2011.02.002PubMedGoogle ScholarCrossref
2.
Adler  Y , Charron  P , Imazio  M ,  et al; ESC Scientific Document Group.  2015 ESC Guidelines for the diagnosis and management of pericardial diseases: the Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC).   Eur Heart J. 2015;36(42):2921-2964. doi:10.1093/eurheartj/ehv318PubMedGoogle ScholarCrossref
3.
Dudzinski  DM , Mak  GS , Hung  JW .  Pericardial diseases.   Curr Probl Cardiol. 2012;37(3):75-118. doi:10.1016/j.cpcardiol.2011.10.002PubMedGoogle ScholarCrossref
4.
Ariyarajah  V , Spodick  DH .  Acute pericarditis: diagnostic cues and common electrocardiographic manifestations.   Cardiol Rev. 2007;15(1):24-30. doi:10.1097/01.crd.0000210645.89717.34PubMedGoogle ScholarCrossref
5.
Tingle  LE , Molina  D , Calvert  CW .  Acute pericarditis.   Am Fam Physician. 2007;76(10):1509-1514.PubMedGoogle Scholar
6.
Patton  KK , Ellinor  PT , Ezekowitz  M ,  et al; American Heart Association Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology and Council on Functional Genomics and Translational Biology.  Electrocardiographic early repolarization: a scientific statement from the American Heart Association.   Circulation. 2016;133(15):1520-1529. doi:10.1161/CIR.0000000000000388PubMedGoogle ScholarCrossref
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