Ruling in Ischaemia on ECG

At Cardiac Bootcamp we look at ischaemia on ECG and go over how to differentiate it from Pericarditis or Benign Early Repolarisation.

Follow these 4 rules to increase your chances of picking up ischaemia. See the examples below.

A 38 yo patient presents with chest pain. The ECG is shown below.
​Is this ischaemia, pericarditis or benign early repolarisation(BER)?

Let's answer the 4 questions. This ECG is not a straight-forward rule in.

1. Is there ST depression in any lead other than aVR and V1
   1. There may potentially be some ST depression in III- This could be ischaemia
   2. There is also some PR depression, which may point to pericarditis
2. Is STE III>II
   1. No
   2. There is some STE in I, aVL, II, V4-V6- Too many territories to be ischaemia
3. Is there a QRT Sign or a convex segment
   1. No
4. Are there hyperacute T waves
   1. No

This is probably not an ischaemic ECG. Can we rule in Pericarditis or BER next?

Changes that make Pericarditis more likely than BER:

1. No fish hook, ie., J point, especially in V4
2. (Spodick’s Sign: There is a downslope of the ST-T segment.)
3. ​ST segment elevation/T wave in V6 is >0.25

The diagnosis is pericarditis.