ST-segment Elevation In aVR Research Articles

Diagnostic and prognostic value of ST-segment deviation scores in suspected acute myocardial infarction.

Recent advances in digital electrocardiography technology allow evaluating ST-segment deviations in all 12 leads as quantitative variables and calculating summed ST-segment deviation scores. The diagnostic and prognostic utility of summed ST-segment deviation scores is largely unknown. We aimed to explore the diagnostic and prognostic utility of the conventional and the modified ST-segment deviation score (Better Analysis of ST-segment Elevations and Depressions in a 12- Lead-ECG-Score (BASEL-Score): sum of elevations in the augmented voltage right - lead (aVR) plus absolute, unsigned ST-segment depressions in the remaining leads) in patients presenting with suspected non-ST-segment elevation myocardial infarction. The diagnostic endpoint was non-ST-segment elevation myocardial infarction, adjudicated by two independent cardiologists. Prognostic endpoint was mortality during two-year follow up. Among 1330 patients, non-ST-segment elevation myocardial infarction was present in 200 (15%) patients. Diagnostic accuracy for non-ST-segment elevation myocardial infarction as quantified by the area under the receiver-operating-characteristics curve was significantly higher for the BASEL-Score (0.73; 95% confidence interval 0.69-0.77) as compared to the conventional ST-segment deviation score (0.53; 95% confidence interval 0.49-0.57, p<0.001). The BASEL-Score provided additional independent diagnostic value to dichotomous electrocardiogram variables (ST-segment depression, T-inversion, both p<0.001) and to high-sensitivity cardiac troponin (p<0.001) as well as clinical judgment at 90 min (p<0.001). Similarly, only the BASEL-Score proved to be an independent predictor of two year mortality. The modified ST-segment deviation score BASEL-Score focusing on ST-segment elevation in aVR and ST-segment depressions in the remaining leads provides incremental diagnostic and prognostic information.

Prognostic implications of ST-segment elevation in lead aVR in patients with acute coronary syndrome: A meta-analysis.

BackgroundST‐segment elevation (STE) in lead aVR is a useful tool in recognizing patients with left main or left anterior descending coronary obstruction during acute coronary syndrome (ACS). The prognostic implication of STE in lead aVR on outcomes has not been established.MethodsWe performed a systematic search for clinical studies about STE in lead aVR in four databases including PubMed, EMBASE, Cochrane Library, and Web of Science. Primary outcome was in‐hospital mortality. Secondary outcomes included in‐hospital (re)infarction, in‐hospital heart failure, and 90‐day mortality.ResultsWe included 7 studies with a total of 7,700 patients. The all‐cause in‐hospital mortality of patients with STE in lead aVR during ACS was significantly higher than that of patients without STE (OR: 4.37, 95% CI 1.63 to 11.68, p = .003). Patients with greater STE (>0.1 mV) in lead aVR had a higher in‐hospital mortality when compared to lower STE (0.05–0.1 mV) (OR: 2.00, 95% CI 1.11–3.60, p = .02), However, STE in aVR was not independently associated with in‐hospital mortality in ACS patients (OR: 2.72, 95% CI 0.85–8.63, p = .09). The incidence of in‐hospital myocardial (re)infarction (OR: 2.77, 95% CI 1.30–5.94, p = .009), in‐hospital heart failure (OR: 2.62, 95% CI 1.06–6.50, p = .04), and 90‐day mortality (OR: 10.19, 95% CI 5.27–19.71, p < .00001) was also noted to be higher in patients STE in lead aVR.ConclusionsThis contemporary meta‐analysis shows STE in lead aVR is a poor prognostic marker in patients with ACS with higher in‐hospital mortality, reinfarction, heart failure and 90‐day mortality. Greater magnitude of STE portends worse prognosis. Further studies are needed to establish an independent predictive role of STE in aVR for these adverse outcomes.

Is isolated ST segment elevation in Lead aVR associated with high grade coronary artery disease?

BackgroundThe diagnostic accuracy of lead aVR ST-segment elevation for left main or triple vessel disease (LM/3VD) has not been universally accepted. In the present analysis we sought to evaluate the diagnostic accuracy of STEaVR in patients presenting with an acute coronary syndrome (ACS). MethodsPooled sensitivity, specificity, positive, and negative likelihood ratios were calculated using a random effects model (DerSimonian-Laird Method) for computing summary estimates and receiver operator curve (ROC) analysis for evaluating overall diagnostic accuracy. ResultsThis meta-analysis included 14 studies. The pooled sensitivity of STEaVR for LM/3VD was 0.40 (95% CI; 0.38 0.43, p < 0.001), specificity 0.82 (95% CI; 0.81–0.83, p < 0.001). Pooled positive likelihood ratio 2.49 (95% CI; 1.62–3.81, p < 0.001) and negative likelihood 0.54 (95% CI; 0.39–0.76, p < 0.001). The pooled sensitivity of STEaVR for LM was 0.39 (95% CI; 0.34–0.45, p < 0.001) specificity was 0.86 (95% CI; 0.85–0.87, p < 0.001) with an AUC of 0.79. The pooled positive likelihood ratio (LR) for LM was 2.78 (95% CI, 2.28–3.39, p < 0.001) negative likelihood ratio 0.51 (95% CI, 0.33–0.78, p < 0.001). ConclusionOur study shows that in patients presenting with an ACS, presence of STEaVR may indicate the presence of LM or 3VD. STEaVR has a high specificity for both LM and 3VD, with a high pooled LR.

Significance of Lead aVR ST Segment Elevation in Patients Presenting with NSTEMI Acute Coronary Syndrome as a Predictor of Left Main Coronary Artery Lesions

Abstract Background: Left main coronary artery (LMCA) occlusion is a serious clinical condition. Despite its low incidence, the prognosis is grave. It may present as sudden death, complete heart block, shock and/or acute coronary syndrome (ACS). Aim of Study: The study aimed to investigate the value of ST-segment elevation in lead aVR in the surface ECG as a predictor of LMCA lesions in patients suffering from non-ST-segment elevation myocardial infarction (NSTEMI) and its relation to the severity of LMCA. Material and Methods: It is a retrospective study including patients admitted to CCU in Banha University Hospital, Shebin El-Kom Teaching Hospital and National Heart Institute. A total number of 100 patients with the diagnosis of NSTEMI ACS who had significant LMCAD on coronary angiography were included in this study; the patients were classified according to the presence or absence of ST-segment elevation of >!0.05mV in lead aVR into two groups: - Group 1: Patients with isoelectric ST-segment in lead aVR or with ST-segment elevation of less than 0.05mV. - Group 2: Patients with ST-segment elevation of 0.05mV or more in aVR. Results: Patients with elevated ST segment more than 1 is significantly higher among patients who died than those who are still alive (p<0.001). Twenty eight patients (37.8%) had Left Main coronary disease in group 2, less than 80% stenosis compared to 18 (75%) patients in group 1. While 46 patients (62,2%) had Left Main stenosis more than 80% In group 2, compared to 6 patients (25%) in group 1, the differences between subgroups were statistically signif-icant difference (p-value <0.001). Conclusion: ST-segment elevation in lead aVR is a sen-sitive prognostic indicator in detecting left main coronary artery lesions of patients suffering from non-ST-segment elevation myocardial infarction (NSTEMI).

Značaj prehospitalnog prepoznavanja ST elevacije u aVR odvodu u akutnom koronarnom sindromu

Introduction/Objective the acute coronary syndrome is a medical condition that Emergency Medical Service physicians deal with daily. An especially prompt reaction is required when an ST elevation in the aVR lead is discovered, as it signifies a critical coronary lesion. The objective of the article is to present how educated the Emergency Medical Service doctors included in the STEMI network are in recognizing and treating the aVR lead elevation, as an atypical ECG finding. Case report Three patients with chest pain lasting from 30 minutes to 2.5 hours are presented. The ECG recording shows significant ST segment depressions >1mm in 6 or more leads (I, II, III, aVL, aVF, V2-V6) coupled with a 3-4mm ST elevation in the aVR lead and similar or slightly less pronounced ST elevation in V1. The strategy for primary PCI had been initialized for all three patients, who were then, after consultation with interventional cardiologists in UHMC Bezanijska kosa, Clinical Hospital Centre Zvezdara and the Military Medical Academy and having taken the initial dose of dual antiplatelet therapy (except for the third patient), transported to the hospital catheterization labs in these three institutions. Conclusion ST segment depression of 1 mm or more in six or more leads (inferolateral depression) coupled with ST segment elevation in aVR and/or V1 points to the threevessel disease (3VD) or left main coronary artery (LMCA) obstruction. The Emergency Medical Service doctors react adequately and promptly and, pending consultation with interventional cardiologists, the patients arrive directly into the catheterization lab. The final decision about reperfusion therapy is made by cardiologists and cardiac surgeons. Early invasive approach and adequate therapy (PCI/CABG) lower the risk of cardiogenic shock development and death.

Prevalence of single and double vessel disease in aVR ST-segment elevation (aVR-STE) and acute coronary syndrome (ACS) by coronary angiography

Prevalence of single and double vessel disease in aVR ST-segment elevation (aVR-STE) and acute coronary syndrome (ACS) by coronary angiography

P5016Usefulness of different electrocardiographic patterns as predictors of in-hospital mortality in acute pulmonary embolism

Abstract Background Many electrocardiographic (ECG) patterns may be present in acute pulmonary embolism (PE), but their prevalence and association with in hospital mortality (IHM) are less well established. Objective Assess the correlation between different ECG patterns and IHM in patients (Pts) with PE using a whole country dataset. Methods Prospective multicenter registry which included Pts with acute PE hospitalized in 75 academic centers from October 2016 to November 2017. We considered the following ECG patterns: sinus tachycardia, pulmonary P waves, Q waves in DII-aVF leads, negative T waves in V1-V4, ST segment elevation in aVR and V1, atrial fibrillation or atrial flutter (AF/AF), right bundle branch block (RBBB), ST segment depression, S1Q3T3 pattern or Qr in V1. Statistical analysis was carried out using de STATA version 13.1. A value of p&lt;0.0.5 was considered statistically significant. Results We included 684 Pts; mean age 63.8±16.7 years (43% male). Global IHM was 12%. The most prevalent ECG patterns were sinus tachycardia (51.7%), S1Q3T3 (24.5%), negative T waves in V1- V4 (16%), RBBB (9.9%), AF/AF (8.6%). Four ECG patterns remained statistically significant predictors of IHM on multivariate analysis: AF/AF (OR: 3.81; CI 95% 1.82–7.95, p&lt;0.01), pulmonary P waves (OR: 3.81; CI 95% 1.2–12, p&lt;0.04), RBBB (OR: 2.71; CI 95% 1.39–5.30, p&lt;0.01) and sinus tachycardia (OR: 2.05; CI 95% 1.18–3.54, p&lt;0.04). ECG pattern and in-hospital mortality.Multivariate analysis Electrocardiographic pattern OR CI 95% p value AF/AF 3.81 1.82–7.95 &lt;0.01 Pulmonary P waves 3.81 1.20–12.00 &lt;0.04 RBBB 2.71 1.39–5.30 &lt;0.01 Sinus tachycardia 2.05 1.18–3.54 &lt;0.04 Q waves in DII-aVF 0.93 0.32–2.64 0.89 ST segment depression 1.07 0.39–2.96 0.80 Negative T waves in V1-V4 0.93 0.47–1.81 0.83 S1Q3T3 pattern 0.75 0.39–1.41 0.37 Qr in V1 2.07 0.63–6.73 0.22 ST segment elevation in aVR 2.38 0.79–7.15 0.12 Conclusions We corroborate the usefulness of the ECG as a prognostic tool in acute PE. Four simple ECG patterns (AF/AF, Pulmonary P waves, RBBB and sinus tachycardia) were associated with a higher IHM and therefore should be considered for PE risk stratification.

Should the primary percutaneous coronary intervention pathway be redesigned?

Background/Aims The primary percutaneous coronary intervention pathway for patients experiencing an ST segment elevation acute coronary syndrome excludes patients with aVR ST elevation. These patients are treated on the non-ST segment elevation acute coronary syndrome pathway, which means that they have a coronary angiogram +/− intervention during their inpatient stay. Patients with non-ST segment elevation acute coronary syndrome have worse outcomes nationally. As such, research is required to demonstrate areas for improvement. This article examines the association between aVR ST segment elevation on the electrocardiogram and significant left main stem, proximal left anterior descending, or 3-vessel coronary artery stenosis in acute coronary syndrome to establish whether the primary percutaneous coronary intervention pathway should be redesigned. Methods Existing literature was searched, and relevant studies were considered and evaluated. Data were collected within local NHS Trusts on patients who had aVR ST segment elevation on the electrocardiogram. The data were analysed, and the findings were compared and synthesised with the literature. Results The study demonstrated a relationship between aVR ST segment elevation and significant disease. However, because of the numbers involved, analysis to demonstrate statistical significance was not possible, with the exception of aVR ST segment elevation and left main stem coronary artery, left anterior descending coronary artery and triple vessel disease, where p&lt;0.05 in the population with left main stem coronary artery occlusion +/− other disease. The study demonstrated that aVR ST segment elevation should be treated as an ST segment elevation acute coronary syndrome equivalent, as it is a high-risk finding. These patients should go immediately to the cardiac catheter laboratory for a primary percutaneous coronary intervention. Conclusion The need for a change in the primary percutaneous coronary intervention pathway was established.

IS AN ISOLATED ST SEGMENT ELEVATION IN LEAD AVR ASSOCIATED WITH HIGH GRADE CORONARY ARTERY DISEASE? SYSTEMATIC REVIEW

The diagnostic accuracy of lead aVR ST-segment elevation for left main or triple vessel disease (LM/3VD) has not been universally accepted. In the present analysis we sought to evaluate the diagnostic accuracy of STEaVR in patients presenting with an acute coronary syndrome (ACS). Pooled

Diffuse ST segment depression and ST segment elevation in lead aVR and V1 by left circumflex artery occlusion

The current guidelines for resting electrocardiograms of diffuse ST segment depression coupled with ST segment elevation in aVR and/or V1 that are otherwise unremarkable indicate multivessel or left main coronary artery obstruction. However, our case meets the above electrocardiogram changes, but involves left circumflex artery occlusion.

AVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion

BackgroundIdentification of ST elevation myocardial infarction (STEMI) is critical because early reperfusion can save myocardium and increase survival. ST elevation (STE) in lead augmented vector right (aVR), coexistent with multilead ST depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multilead ST depression. MethodsSTEMI activations between January 2014 and April 2018 at the University of Arizona Medical Center were identified. All electrocardiograms (ECGs) and coronary angiograms were blindly analyzed by experienced cardiologists. Among 847 STEMI activations, 99 patients (12%) were identified with STE-aVR with multilead ST depression. ResultsEmergent angiography was performed in 80% (79/99) of patients. Thirty-six patients (36%) presented with cardiac arrest, and 78% (28/36) underwent emergent angiography. Coronary occlusion, thought to be culprit, was identified in only 8 patients (10%), and none of those lesions were left main or left anterior descending occlusions. A total of 47 patients (59%) were found to have severe coronary disease, but most had intact distal flow. Thirty-two patients (40%) had mild to moderate or no significant disease. However, STE-aVR with multilead ST depression was associated with 31% in-hospital mortality compared with only 6.2% in a subgroup of 190 patients with STEMI without STE-aVR (p<0.00001). ConclusionsSTE-aVR with multilead ST depression was associated with acutely thrombotic coronary occlusion in only 10% of patients. Routine STEMI activation in STE-aVR for emergent revascularization is not warranted, although urgent, rather than emergent, catheterization appears to be important.

How ST-segment elevation in aVR corelates with occlusion in the left main coronary artery

How ST-segment elevation in aVR corelates with occlusion in the left main coronary artery

Atypical electrocardiographic presentations of myocardial infarction with ST elevation - ST elevation myocardial infarction equivalents

Introduction. Some patients with clinical symptoms and signs of acute myocardial and coronary artery occlusion have atypical electrocardiographic presentations - ST elevation myocardial infarction equivalents. Rapid recognition of these patterns is imperative, because the condition requires prompt reperfusion therapy following actual guidelines. De Winter pattern. Diagnostic criteria are: tall, prominent, symmetrical T-waves in the precordial leads, upsloping ST segment depression &gt; 1 mm at the J-point in the precordial leads, absence of ST elevation in the precordial leads, ST segment elevation (0.5 mm - 1 mm) in aVR. ST Elevation in aVR. Electrocardiographic criteria include ST segment elevation in aVR ? 1 mm, ST segment elevation in aVR ? V1, and diffuse ST segment depression in lateral leads. Wellens syndrome. Wellens syndrome describes deeply inverted or bi?phasic T-waves in leads V2 - V3, highly specific for significant stenosis of the left anterior descending artery. Posterior infarction. Posterior infarction is confirmed with ST segment depression ? 0,5 mm in leads V1 - 3 and ST segment elevation ? 0.5 mm in posterior leads (V7 - V9). Conclusion. There are many electrocardiographic patterns that physicians should promptly recognize as clinical myocardial infarction with ST segment elevation equivalents in order to perform urgent reperfusion therapy for better prognosis and survival in these patients.

The added value of ST-elevation in lead aVR to clinical thrombolysis in myocardial infarction risk score in predicting the angiographic severity and extent of coronary artery disease in patients with non-ST-elevation acute coronary syndrome

Introduction The use of ST-segment elevation (STE) in lead aVR in addition to thrombolysis in myocardial infarction (TIMI) risk score may improve the early risk stratification and the management of patients at high-risk coronary artery disease, with subsequent effect on morbidity and mortality. Patients and methods A total of 65 patients who underwent coronary angiograms in Sohag Heart Specialized Center in the period between September 2013 and March 2014 were the participants of the study. All patients were subjected to full history taking, clinical evaluation, laboratory investigations, ECGs, TIMI scoring, and coronary angiography by femoral approach. Results Of the 65 patients, 59 patients were found to have significant coronary artery disease with 39 of them had STE in aVR lead, and none of the normal coronary angiography (CA) cases had STE in this lead. Of the 39 with STE-aVR, 13 patients had left main disease and 30 of them had multivessel disease. ST-aVR was elevated in 17 cases with low or intermediate risk according to TIMI score (9.1 and 55% of both groups, respectively), and was normal in three (12%) of the patients with high-risk TIMI score. Thus, STE-aVR could predict another 28.8% of high-risk cases that would not be detected by TIMI. Conclusion STE in lead aVR has a diagnostic and prognostic value in patients with non-STE acute coronary syndrome and may provide an additional prognostic value to the conventional cardiovascular risk factors, particularly in patients from the TIMI low-risk and intermediate-risk groups.

Prediction of Significant Left Main Coronary Artery Disease using ST-segment Elevation in aVR Among Adult Patients with Acute Coronary Syndrome Admitted at a Tertiary Hospital from January 2011 through December 2015

Introduction: This study aims to determine whether ST-segment elevation in aVR predicts significant left main coronary artery (LMCA) disease among adult patients with acute coronary syndrome (ACS). Method: This retrospective study enrolled adult patients, aged 18 years and above, who were diagnosed with ACS, have undergone coronary angiogram, with retrievable electrocardiogram tracings, and were admitted at a tertiary hospital from January 1, 2011 through December 31, 2015. Results: A total of 276 patients were included in the study, majority of them were male, and the mean age was 60+12 years. Forty-three patients had significant LMCA disease, 18 with ST-segment elevation in aVR; 24 patients had no significant LMCA involvement, with ST-segment elevation in aVR; and 209 had no significant left main disease and did not show ST-segment elevation in aVR. Conclusion: The study showed that ST-segment elevation of 0.13 mV in aVR has a sensitivity of 92.9%, specificity of 2.1%, likelihood ratio of 0.95, positive predictive value (PPV) of 14.6% and negative predictive value (NPV) of 62.5% in predicting a significant LMCA disease. ST elevation in aVR has high sensitivity but low specificity, LPV and NPV for predicting significant LMCA disease. Keywords: ECG changes in left main coronary artery disease, ST-segment elevation in aVR.

Exercise test predictors of severe coronary artery disease: Role of ST‐segment elevation in lead aVR

The role of exercise stress test (EST)-induced ST-segment elevation (STE) in electrocardiographic lead aVR in predicting severe coronary artery disease (CAD) is controversial. Assessment of lead aVR during EST can be helpful to identify patients with severe CAD. We performed maximal EST in 200 patients undergoing coronary angiography for suspect of CAD. Four angiographic findings of severe CAD were considered: (1) left main (LM) disease; (2) LM or equivalent LM (LM/EQLM) disease; (3) LM or proximal left anterior descending (LAD) artery (LM/proxLAD) disease; and (4) LM or 3-vessel (LM/3V) disease. LM, LM/EQLM, LM/proxLAD, and LM/3V disease were shown in 6 (3%), 13 (6.5%), 33 (16.5%), and 27 (13.5%) patients, respectively. EST-induced STE in aVR occurred in 41 patients (20.5%). ST-segment depression (STD) in ≥5 leads was the only predictor of LM stenosis (odds ratio [OR]: 6.18, 95% confidence interval [CI]: 1.19-32.2, P = 0.03) and the most significant variable associated with LM/proxLAD stenosis (OR: 4.73, 95% CI: 2.0-11.2, P = 0.0001); maximal STD ≥3 mm was the most significant variable associated with LM/EQLM (OR: 7.58, 95% CI: 2.31-24.9, P = 0.001) and LM/3V (OR: 3.86, 95% CI: 1.47-10.1, P = 0.006) CAD. EST-induced STE in aVR was associated with LM/proxLAD disease only (OR: 3.23, 95% CI: 1.44-7.24, P = 0.004). At multivariate analysis, STD in ≥5 leads was the only independent predictor of LM/proxLAD disease (OR: 3.99, 95% CI: 1.58-10.1, P = 0.003). EST-induced STE in lead aVR does not significantly increase the prediction of severe CAD compared with severity and extension of STD as assessed in the other electrocardiographic leads.

ST-segment elevation in lead aVR in the setting of acute coronary syndrome

Objectives The purpose of our study was to assess the value of aVR ST-segment elevation (STE) during acute non ST-segment elevation myocardial infarction (NSTEMI) or unstable angina. Background STE in lead aVR has been associated with severe coronary lesions in patients with acute coronary syndromes. However, there are conflicting data regarding the prognostic significance of this finding.Methods We evaluated the initial electrocardiogram (ECG) in 129 patients admitted to our hospital with acute NSTEMI or unstable angina without STE in leads other than aVR or V1. STE in aVR lead was measured and echocardiography and coronary angiography were performed within 48-72 hours after hospitalization. Results Overall, 40.3% (52 patients) had more than 0.05 mv STE in lead aVR. These patients had an increased prevalence of ST ≥ 1 mm in lead V1, a more frequent and extensive ST-segment depression (STD) in other leads, a higher prevalence of anterior and lateral STD and a lower frequency of isolated negative T waves. It was also strongly associated with cardiac enzyme rising and a trend toward higher 3-month mortality. Furthermore, patients with STE in lead aVR were more likely to have three-vessel or multivessel disease, higher Gensini score of the coronary arteries, lower left ventricular ejection fraction (LVEF) and higher incidence of mitral regurgitation (MR).Conclusions Our study showed that among ECG markers, the sole criterion STE in lead aVR was independently associated with atherosclerosis severity and decreased LVEF. Also, it was significantly associated with the presence of MR.

Image diagnosis: aVR, the forgotten lead.

The 12-lead electrocardiogram has been referred to as an “11-lead study” on the basis of the false assumption that lead aVR yields only limited information. As this area is already covered by other leads (I, aVL, V5, V6), aVR was only used to confirm correct arm lead placement and was assumed to reflect only reciprocal changes from the lateral portion of the heart. As a result, the unpaired lead aVR has been largely ignored and has been coined the “forgotten lead.”1 In reality, aVR is an informative lead that also reflects the right ventricular outflow tract and the basal portion of the interventricular septum. Analysis of aVR’s individual waveforms should be performed in concert with all other leads because it can provide critical information in the management of a number of medical conditions. The ST segment in lead aVR is used in the assessment of narrow complex tachyarrhythmia. Ho et al2 reported the presence of ST elevation in aVR has a 71% sensitivity and a 70% specificity of distinguishing atrial ventricular reciprocating tachycardia (such as Wolff-Parkinson-White) from atrial ventricular nodal reentrant tachycardia. In addition, aVR morphology can also be used to distinguish wide complex supraventricular tachycardia from ventricular tachycardia. For example, in 2008 Vereckei et al3 reported a 98% sensitivity in differentiating wide complex supraventricular tachycardia from ventricular tachycardia based solely on the analysis of aVR morphology (Figure 1). Figure 1. aVR criteria from Vereckei et al1 suggestive of ventricular tacychardia: 1) presence of R wave; 2) presence of R wave or Q wave > 40 msec; 3) presence of a notch on the descending limb of the negative QRS complex; 4) voltage change in the first ... The presence of a prominent R wave in aVR is a critical finding in sodium channel blocker poisonings, such as with tricyclic antidepressants.4 Liebelt et al4 concluded that an R wave amplitude > 3.0 mm is more sensitive than QRS interval as a predictor of seizures and ventricular dysrhythmias (Figure 2). Figure 2. 12-lead electrocardiogram with a sinus rhythm characterized by a widened QRS complex, deep S wave in lead I, and prominent R wave in lead aVR. These findings are consistent with cardiotoxicity resulting from tricyclic antidepressant poisoning. Patient ... Finally, aVR is a valuable lead in the management of acute coronary ischemia. Although aVR ST-segment elevation may be an abnormal variant in supraventricular tachycardia, bundle branch blocks, left ventricular hypertrophy, or right ventricular hypertrophy, in the presence of other ischemic changes aVR ST-segment elevation is a sensitive indicator of left main, left anterior descending, or triple vessel disease.5–9 Barrabes et al6 and Kosuge et al7 have reported aVR ST-segment elevation to be an independent risk factor for increased morbidity and mortality. Therefore, the presence of aVR ST-segment elevation, in conjunction with other ischemic changes, should be considered an ST-segment elevation myocardial infarction equivalent and warrants immediate interventional reperfusion6,7,10 (Figure 3). Figure 3. 12-lead electrocardiogram from a 33-year-old man with history of hypercholesterolemia, who presented to the Emergency Department with 5 hours of anterior chest pressure associated with diaphoresis and shortness of breath. Electrocardiogram demonstrates ...

10.5937/mckg48-4068 = Diagnostic and prognostic utility of aVR lead in electrocardiogram

When interpreting electrocardiograms aVR lead is often neglected although it provides significant diagnostic and prognostic capabilities. This lead looks directly at the upper right side of the heart and provides specific information concerning the outflow tract of the right ventricle and the basal part of the ventricular septum. This part of the septum is usually nourished by the septal branch of the proximal part of the RIA. Because of this, the literature shows that ST segment elevation in aVR ≥ 1 lead during acute coronary events may indicate occlusion of the left main coronary artery, occlusion of proximal RIA or severe three-vessel disease. This may help in the diagnosis and proper treatment in these patients.

ST Segment Elevation in aVR: Clinical Significance in Acute Coronary Syndrome

A 59-year-old-male patient with no previous medical history presented with oppressive chest pain; initial electrocardiogram showed ST segment elevation in aVR and V1, with intermittent right bundle branch block. Emergent coronary angiogram showed a proximal sub-occlusive stenosis of the left anterior descending artery, and the patient was hemodynamically unstable during the first 72 hours. Insights into the significance of ST segment elevation in aVR are presented and discussed in light of the current medical data.