Abstract
BackgroundIn the standard ECG display, limb leads are presented in a non-anatomical sequence: I, II, III, aVR, aVL, aVF. The Cabrera system is a display format which instead presents the limb leads in a cranial/left-to-caudal/right sequence, i.e. in an anatomically sequential order. Lead aVR is replaced in the Cabrera display by its inverted version, −aVR, which is presented in its logical place between lead I and lead II.Main textIn this debate article possible implications of using the Cabrera display, instead of the standard, non-contiguous lead display, are presented, focusing on its use in patients with possible acute coronary syndrome. The importance of appreciating reciprocal limb-lead ECG changes and the diagnostic and prognostic value of including aVR or lead −aVR in ECG interpretation in acute coronary syndrome is covered. Illustrative cases and ECGs are presented with both the standard and contiguous limb lead display for each ECG.A contiguous lead display is useful when diagnosing acute coronary syndrome in at least 3 ways: 1) when contiguous leads are present adjacent to each other, identification of ST elevation in two contiguous leads is simple; 2) a contiguous lead display facilitates understanding of lead relationships as well as reciprocal changes; 3) it makes the common neglect of lead aVR unlikely.ConlusionsIt is logical to display the limb leads in their sequential anatomical order and it may have advantages both in diagnostics and ECG learning.
Highlights
In this debate article possible implications of using the Cabrera display, instead of the standard, noncontiguous lead display, are presented, focusing on its use in patients with possible acute coronary syndrome
ECG changes indicative of acute coronary occlusion or sub-occlusion serve as an important “watershed” in the early decision process in the management of patients with chest pain
ECG interpretation skills are essential for any physician who encounters patients with suspected acute coronary syndrome
Summary
The Cabrera display for diagnosing acute coronary syndrome The ECG is an essential diagnostic tool, since it is available very early in the management of patients with suspected acute coronary syndrome, often considerably earlier than biomarkers and other diagnostic modalities. Kosuge et al showed that in patients with ST elevation in the precordial leads, ST depression in aVR was more common in patients with takotsubo cardiomyopathy than in patients with LAD occlusion and suggested that this was more recognized by the use of the Cabrera sequence (Fig. 5) [37]. The focus of this debate paper is acute coronary syndrome. Future studies on the value of the Cabrera sequence compared to the standard display format are needed and encouraged, especially regarding sensitivity and specificity for the diagnosis of acute coronary syndrome
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