Downsloping TP segment seen as an early ECG manifestation in ~80% of patients with pericarditis, best visualised in leads II and the lateral precordial leads

Spodick sign V4 downsloping TP segment
Spodick sign: Downsloping TP segment

ECG changes associated with Stage I pericarditis, first described by David H. Spodick in 1974. The sign remained relatively unevaluated until a recent retrospective analysis in 2020. Witting et al, considered an ECG to demonstrate Spodick’s sign when at least two leads had TP downsloping of at least 1 mm.

Clinical significance
  • Potential useful distinguishing ECG feature between acute pericarditis and ACS
  • Witting found that Spodick’s sign occurred in 29% of patients with pericarditis and 5% of patients with STEMI (OR 5.9)
  • PR depression alone can be a masquerader as it is seen in 12% of patients with STEMI
  • A separate prospective study by Porela et al found that PR depression had a high sensitivity (88%) for myopericarditis but a low specificity

Differentiating STEMI from pericarditis

The most discriminating features remain as ST depression, ST elevation in lead III >II, and absence of PR depression. It is thus still recommended to look for features of STEMI first on the ECG with ST elevation:

  • Search for ST depression (aside from leads aVR and V1)
  • Look for ST elevation in III > II
  • Search for horizontal or convex upward ST elevation

Following this, additional features such as Spodick’s sign can be reviewed to further differentiate the diagnosis of pericarditis.

Adapted from “Evaluation of Spodick’s sign”: Witting et al

ECG Pericarditis 2

Acute pericarditis:

  • Sinus tachycardia
  • Widespread concave STE and PR depression (I, II, III, aVF, V4-6).
  • Reciprocal ST depression and PR elevation in V1 and aVR
  • Spodick’s sign best visualised in lead II

Associated Persons

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MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books |

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