We examined the quantitative electrocardiographic differentiation of acute pericarditis from normal variant ST-T changes. The ECGs of 19 patients with acute pericarditis were compared with those of 20 subjects with typical normal variant changes. Patients were excluded if their ECGs demonstrated conditions that markedly altered repolarization. The positive predictive values (PPV) and negative predictive values (NPV) of previously reported criteria were not high (PPV = 0.54-0.83, NPV = 0.56-0.58). In contrast, in the present study, a T-wave amplitude in lead V6 of less than or equal to 0.3 mV diagnosed acute pericarditis (p less than 0.005, PPV = 0.85, NPV = 0.85), but there was overlap of patients between the groups. The ratio of the amplitude of the onset of the ST segment to the amplitude of the T wave in that lead (ST/T ratio in V6) proved to be the most reliable discriminator. An ST/T ratio greater than or equal to 0.25 diagnosed all patients with acute pericarditis (p less than or equal to 0.005, PPV = 1.0, NPV = 1.0). The ST/T ratio greater than 0.25 in V4, V5 (both p less than 0.005, PPV = 0.87, NPV = 1.0) and I (p less than or equal to 0.005, PPV = 0.80, NPV = 0.81) were also significant discriminators. Thus, if V6 is unavailable, an ST/T ratio greater than or equal to 0.24 in V5, V4 or I is highly suggestive of acute pericarditis. An ST/T ratio greater than or equal to 0.25 in V6 discriminated the ECGs of all patients with acute pericarditis from normal variants in this study.