Lead aVR Research Articles

556 ST Segment Elevation in Lead AVR: Initial Management and Outcomes

556 ST Segment Elevation in Lead AVR: Initial Management and Outcomes

Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review

BackgroundAcute myocarditis represents a challenging diagnosis as there is no pathognomonic clinical presentation. In patients with myocarditis, electrocardiogram (ECG) can display a variety of non‐specific abnormalities. Nevertheless, ECG is widely used as an initial screening tool for myocarditis.MethodsWe researched all possible ECG alterations during acute myocarditis evaluating prevalence, physiopathology, correlation with clinical presentation patterns, role in differential diagnosis, and prognostic yield.ResultsThe most common ECG abnormality in myocarditis is sinus tachycardia associated with nonspecific ST/T‐wave changes. The presence of PR segment depression both in precordial and limb leads, a PR segment depression in leads with ST segment elevation, a PR segment elevation in aVR lead or a ST elevation with pericarditis pattern favor generally diagnosis of perimyocarditis rather than myocardial infarction. In patients with acute myocarditis, features associated with a poorer prognosis are: pathological Q wave, wide QRS complex, QRS/T angle ≥ 100°, prolonged QT interval, high‐degree atrioventricular block and malignant ventricular tachyarrhythmia. On the contrary, ST elevation with a typical early repolarization pattern is associated with a better prognosis.ConclusionsECG alterations in acute myocarditis could be very useful in clinical practice for a patient‐tailored approach in order to decide appropriate therapy, length of hospitalization, and frequency of followup.

Importance of lead aVR on predicting adverse cardiac events in patients with noncompaction cardiomyopathy.

BackgroundNoncompaction cardiomyopathy (NCCM) is a relatively rare cardiac abnormality with high rates of mortality and morbidity. T‐wave amplitudes during ventricular repolarization in lead aVR (TaVR) have been reported to be associated with the prognosis of various cardiovascular diseases. This study sought to investigate the prevalence and prognostic role of positive TaVR in patients with NCCM.MethodsWe evaluated consecutive 161 patients with NCCM (65.8% men, mean age 42.5 ± 15.2 years old). Presentation electrocardiogram was assessed regarding classical parameters as well as T‐wave amplitudes in lead aVR. The primary endpoint was defined as composite lethal arrhythmic events, including sudden cardiac death, ventricular fibrillation, or sustained ventricular tachycardia or appropriate implantable cardioverter–defibrillator shock. Heart failure requiring hospitalization, cardiovascular death, and all‐cause mortality were also investigated as secondary endpoints.ResultsPatients with positive TaVR showed higher rates for arrhythmic events, hospitalization for heart failure, and death compared with patients without it. In multivariate Cox model, after adjusting for other known clinical and electrocardiographic risk factors, the positive TaVR was found to be a strong independent predictor of primary endpoint (HR: 4.8, 95% CI: 1.2–19.3; p = .025) and all‐cause death (HR: 3.5, 95% CI: 1.0–12.1; p = .045).ConclusionOur findings revealed that positive TaVR is significantly and independently associated with adverse outcomes in NCCM patients. This unique ECG criterion in the often ignored lead provides incremental information beyond what is available with other traditional risk factors.

Association of the positive T wave in lead aVR with short-term mortality in patients with acute pulmonary embolism

Background: Lead aVR provides prognostic information in various settings for patients with cardiovascular diseases. The present study aimed to investigate the prognostic value of a positive T wave in lead aVR (TaVR) for patients with acute pulmonary embolism (APE).Methods: We screened a total of 412 consecutive patients who were hospitalised with a diagnosis of APE between 2008 and 2018. We investigated electrocardiograms (ECGs) for the presence of a positive TaVR and classified other abnormal ECG findings. Additionally, clinical data, such as echocardiographic findings were recorded, and pulmonary embolism severity index (PESI) scores were calculated. The predictors of mortality at 30 days were investigated as the clinical outcome by logistic regression analysis.Results: In our study population, 54 patients (13.1%) died within 30 days. The prevalence of female gender, congestive heart failure, chronic obstructive pulmonary disease, and mean PESI scores were significantly higher in patients with a positive TaVR compared to those without it. Systolic blood pressure of patients with positive TaVR was significantly lower than that of patients without positive TaVR. In multivariate regression analysis; PESI scores (OR: 1.03; 95% CI: 1.01–1.04, p < .01), Right ventricular end-diastolic diameter (RVEDD) (OR: 1.07 95% CI: 1.01–1.13, p = .02), and a positive TaVR (OR: 4.41; 95% CI: 1.63–11.96, p < .01) were independently correlated with mortality.Conclusion: Positive TaVR, PESI scores, and RVEDD at hospital admission may have prognostic value in patients with APE. Positive T wave in lead aVR could be a useful marker in early risk stratification of pulmonary embolism.

Prolonged Tpeak -Tend interval is a risk factor for sudden cardiac death in adults with congenital heart disease.

ObjectiveAdult congenital heart disease (ACHD) patients are at risk of sudden cardiac death (SCD). However, methods for risk stratification are not yet well‐defined. The Tpeak‐Tend (TpTe) interval, a measure of dispersion of ventricular repolarization, is a risk factor for SCD in non‐ACHD patients. We aim to evaluate whether TpTe can be used in risk stratification for SCD in ACHD patients.DesignFrom an international multicenter cohort of 25 790 ACHD patients, we identified all SCD cases. Cases were matched to controls by age, gender, congenital defect, and (surgical) intervention.Outcome MeasuresTpTe was measured on a standard 12‐lead ECG. The maximum TpTe of all ECG leads (TpTe‐max), mean (TpTe‐mean), and TpTe dispersion (maximum minus minimum) were obtained. Odds ratios (OR) for SCD cases vs controls were calculated using conditional logistic regression analysis.ResultsECGs were available for 147 cases (median age at death 33.5 years (quartiles 26.2, 48.7), 66% male) and 267 controls. The mean TpTe‐max was 97 ± 24 ms in cases vs 84 ± 17 ms in controls (P < .001); TpTe‐mean was 70 ± 16 vs 63 ± 10 ms (P < .001); and dispersion was 51 ± 22 ms vs 41 ± 16 ms (P = .02), respectively. Assessing each ECG lead separately, TpTe in lead aVR predicted SCD most accurately. TpTe in lead aVR was 71 ± 23 ms in cases vs 61 ± 13 ms in controls (P < .001). After adjusting for impaired ventricular function, heart failure symptoms, and prolonged QRS duration, the OR of SCD of TpTe in lead aVR at an optimal cutoff of 80 ms was 5.8 (95% CI 2.7‐12.4, P < .001).ConclusionsThe TpTe interval is associated with SCD in ACHD patients. Particularly, TpTe in lead aVR can be used as an independent risk factor for SCD in ACHD patients and may, therefore, add precision to current risk prediction models.

Simple electrocardiographic criteria for rapid identification of wide QRS complex tachycardia: The new limb lead algorithm

The electrocardiogram (ECG) is essential for the differential diagnosis of wide QRS complex tachycardia (WCT). The purpose of this study was to evaluate the diagnostic value of a novel ECG algorithm on the basis of the morphological characteristics of the QRS on the limb leads. The limb lead algorithm (LLA) was evaluated by analyzing 528 monomorphic WCTs with electrophysiology-confirmed diagnoses. In the LLA, ventricular tachycardia (VT) is diagnosed in the presence of at least 1 of the following: (1) monophasic R wave in lead aVR; (2) predominantly negative QRS in leads I, II, and III; and (3) opposing QRS complex in the limb leads: concordant monophasic QRS in all 3 inferior leads and concordant monophasic QRS in 2 or 3 of the remaining limb leads with a polarity opposite to that of the inferior leads. The diagnostic performance of the LLA was compared with that of the Brugada, Vereckei, and R-wave peak time (RWPT) algorithms. Of 528 WCT cases, 397 were VT and 131 supraventricular tachycardia. The interobserver agreement for the LLA was excellent (κ = 0.98), better than that for the other algorithms. The overall accuracy of the LLA (88.1%) was similar to that of Brugada (85.4%) and Vereckei (88.1%) algorithms but was higher than that of the RWPT algorithm (70.8%). The LLA had a lower sensitivity (87.2%) than did Brugada (94.0%) and Vereckei (92.4%) algorithms, but not the RWPT algorithm (67.8%). Furthermore, the LLA showed a higher specificity (90.8%) than did Brugada (59.5%), Vereckei (76.3%), and RWPT (80.2%) algorithms. The LLA is a simple yet accurate method to diagnose VT when approaching WCTs on the ECG.

Value of ST-segment change in lead aVR in diagnosing left main disease in Non-ST-elevation acute coronary syndrome-A meta-analysis.

Previous researches proved that the ST-segment elevation (STE) in lead aVR had great significance on the prediction of severe left main lesion or serious multivessel lesions. The current research is to summarize the published data and evaluate the overall association of STE in lead aVR and left main coronary artery disease (LMD) in Non-ST-elevation acute coronary syndrome. Literature searching was performed in the online database, and a systematic review was conducted based on the searched results. Meaningful STE in lead aVR was summarized and analyzed for odds ratio (OR) and 95% confidence intervals (95% CI). Twenty-seven articles were included for final data analysis. Compared with STE<0.05, STE≥0.05mV was associated with a higher incidence rate of LMD (OR=6.64, 95% CI: 4.80~9.17), and the degree of STE in lead aVR was significantly associated with LMD. Myocardial infarction was more likely to occur in patients with STE≥0.05mV than in patients with STE<0.05mV (OR=3.12, 95% CI: 1.73~5.62). The STE in lead aVR and the degree of STE are independent predictors in diagnosing LMD or myocardial infarction.

Diagnostic value of lead aVR in electrocardiography for identifying acute coronary lesions in patients with out-of-hospital cardiac arrest

AimThere is no simple clinical tool that reliably indicates the presence of acute coronary lesions in out-of-hospital cardiac arrest (OHCA) patients without typical ST-segment elevations. ST-segment elevation in electrocardiographic lead aVR suggests global subendocardial ischemia. This study aimed to evaluate the diagnostic value of lead aVR for identifying acute coronary lesions following resuscitation from OHCA. MethodsA total of 74 patients without evidence of ST-segment elevations, who were resuscitated from OHCA, were examined. The degree of ST-segment elevation in lead aVR was measured directly after return of spontaneous circulation (ROSC) and at early follow-up. Coronary angiograms were retrospectively reviewed. ResultsAcute coronary lesions were detected in 20 patients (27%). No difference in ST-segment elevation in lead aVR directly after ROSC was observed between patients with or without acute coronary lesions. However, ST-segment elevation values significantly decreased at early follow-up (median, 137 min) in patients without acute coronary lesions. An ST-segment elevation ≥0.5 mm in lead aVR at early follow-up was associated with a higher prevalence of multivessel coronary artery disease and was an independent indicator of the presence of acute coronary lesions (odds ratio, 4.41; 95% confidence interval, 1.12–17.4; p = 0.034). ConclusionST-segment elevation in lead aVR at early follow-up was associated with the presence of acute lesions accompanied by severe coronary artery disease in post-cardiac arrest patients without other ST-segment elevations. The analysis of ST-segment elevation in lead aVR may aid in the identification of patients who will benefit from further invasive coronary diagnostic procedures.

A case of left circumflex artery stenosis involving ST segment depression in multiple leads with ST elevation in lead augmented vector right

Electrocardiography (ECG) patterns of ST-segment elevation in lead aVR with or without diffuse ST segment depression may predict either left main coronary artery or triple vessel stenosis. Here, we have presented the case of a 56-year-old female involving such an ECG pattern with ST-segment depression in more than eight leads and ST Segment elevation in lead aVR, however, showing stenosis of the mid-segment of the left circumflex artery (LCX). She was scheduled to undergo percutaneous coronary intervention with implantation of a drug-eluting stent with respect to mid LCX stenosis. The patient was asymptomatic post procedure and was discharged on beta blockers. To conclude, the ECG pattern of ST depression in multiple leads with ST-elevation in aVR lead can occur in LCX obstruction as well.

Diagnostic value of standard electrocardiogram in acute right ventricular myocardial infarction.

Myocardial infarction (MI) (i.e., heart attack) is the irreversible death (necrosis) of heart muscle secondary to prolonged lack of oxygen supply (ischemia) which accounts for a large number of deaths in the hospital. Diagnosis of myocardial infarction is confirmed based on clinical manifestations and electrocardiographic changes along with increased cardiac enzymes. Electrocardiogram (ECG) is one of the safest and easiest methods in the first place. Therefore, this study aimed to investigate the diagnostic value of standard electrocardiogram in the diagnosis of acute right ventricular infarction following lower cardiac infarction. This research was carried out at a time interval of one and a half years to diagnose acute primary infarction. In this method, the diagnostic value of ST↓ in lead I, ST↓ in lead aVL and I ST↓ + aVL, compared with ST↑ in lead V4R was investigated for diagnosis of right ventricular infarction. ST↑ in the lead V4R is a gold standard for the detection of right ventricular MI. All the patients who had the inclusion criteria were allowed to participate in the study. A total of 66 patients participated in the study. Accordingly, 58 (87%) were male and 8 (13%) were female. The mean age of the population was 54.9 ± 11.41. According to the ST↑ standard in lead V4R, 26 patients (39%) had right ventricular myocardial infarction. There was no significant relationship between angina pectoris and premature infarction (P-Value = 0.869). In this study, the right ventricular was most commonly involved in right coronary artery (78%). There was no significant relationship between the occlusion of right coronary artery and right ventricular infarction in 60 patients (P-Value = 0.94). The results showed that electrocardiogram manifestations help determine the occlusion site and the area at risk (ST↓ in lead aVL and aVL + I, sensitivity = 96%). In myocardial infarction, symptoms such as the ST-Segment elevation in lead aVR and ST-Segment depression in the lower leads are possible. Accordingly, in the lower infarction, ST changes in the leads V1-V6 are helpful in detecting patients at risk. Thus, the use of electrocardiogram in acute myocardial infarction helps detect more invasive patients and prevents extensive myocardial damage and other complications.

Risk score for the exclusion of arrhythmic events in arrhythmogenic right ventricular cardiomyopathy at first presentation

AimsArrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetically determined heart muscle disorder associated with an increased risk of life-threatening arrhythmias in some patients. Risk stratification remains challenging. Therefore, we sought a non-invasive, easily applicable risk score to predict sustained ventricular arrhythmias in these patients. MethodsCohort of Patients who fulfilled the 2010 ARVC task force criteria were consecutively recruited. Detailed clinical data were collected at baseline and during follow up. The clinical endpoint was a composite of recurrent sustained ventricular arrhythmias and hospitalization due to ventricular arrhythmias. Multivariable logistic regression was used to develop models to predict the arrhythmic risk. A cohort including patients from other registries in UK, Canada and Switzerland was used as a validation population. ResultsOne hundred and thirty-five patients were included of whom 35 patients (31.9%) reached the endpoint. A model consisting of filtered QRS duration on signal-averaged ECG, non-sustained VT (NSVT) on 24 h-ECG, and absence of negative T waves in lead aVR on 12‑lead surface ECG was able to predict arrhythmic events with a sensitivity of 81.8%, specificity of 84.0% and a negative predictive value of 95.5% at the first presentation of the disease. This risk score was validated in international ARVC registry patients. ConclusionA risk score consisting of a filtered QRS duration ≥117 ms, presence of NSVT on 24 h-ECG and absence of negative T waves in lead aVR was able to predict arrhythmic events at first presentation of the disease.

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

Comparison of ST segment Changes in Lead aVR with in-Hospital Outcomes in Patients with First attack of Acute Inferior ST Segment Elevation Myocardial Infarction

Background: Inferior wall ST segment elevation myocardial infarction is considered to be at lower risk than anterior wall STEMI except in some cases. The aim of our study was to evaluate the relationships between on admission ST segment changes in lead aVR and short term in-hospital outcomes in acute isolated inferior myocardial infarction undergoing thrombolysis.&#x0D; Methods: Total 107 of first attack of inferior STEMI patients were included and all were thrombolysed by streptokinase. The sample population were divided into three groups based on the condition of ST segment in lead aVR on admission and in hospital outcomes were observed: Group –A: ST segment elevation ≥0.5 mm; Group –B: ST segment depression ≥0.5 mm; Group-C: Iso-electric ST segment.&#x0D; Results: 6.54% of study population had ST segment elevation in lead aVR, 53.27% had ST segment depression in lead aVR and 41.12% had isoelectric ST segment in lead aVR. During hospital stay mortality rates of patients of Group A, Group B and Group C were 33.3%, 5.3% and 4.5 % respectively; rates of cardiogenic shock were 33.3%, 8.8% and 2.3% respectively; heart failure rates were 50.0%, 15.8% and 4.5% respectively; rates of recurrent angina after thrombolysis were 66.7%, 33.3% and 6.8% respectively in three groups and the mean LVEF were 40.17, 48.61 and 52.50 respectively.&#x0D; Conclusion: The on admission-isoelectric ST segment in lead aVR in acute inferior myocardial infarction predicted better in-hospital outcomes in comparison to ST segment elevation and ST segment depression in aVR. On the other hand, ST segment elevation in lead aVR predicted worse in-hospital outcomes than ST segment depression in acute inferior myocardial infarction in spite of reperfusion by thrombolytic.&#x0D; Cardiovasc. j. 2019; 11(2): 123-128

Significance of ST Segment Elevation in Lead aVR in Patients with Non-ST Elevation Acute Coronary Syndrome

Background: As acute occlusion of the left main (LM) artery causes life-threatening hemodynamic deterioration and malignant arrhythmias, resulting in an adverse outcome, a rapid diagnosis and subsequent urgent revascularization with percutaneous coronary intervention (PCI) or coronary bypass surgery is very important in this subset of patients. The 12-lead electrocardiogram (ECG) is a crucial tool in the diagnosis and risk stratification of acute coronary syndrome (ACS). Unlike other 11 leads, lead aVR has been long neglected until recent years.&#x0D; Objective: To determine the accuracy of 12-lead electrocardiography in predicting left main and/or triplevessel disease in patients with non-ST elevation acute coronary syndrome (NSTE- ACS). Methodology: This cross sectional observational study carried out among patients presenting with non-ST elevation acute coronary syndrome at Cardiac Emergency Department or CCU of BSMMU. This study was conducted from May 2017 to April 2018. A total of 36 patients meeting the eligibility criteria were consecutively included. Data collection was carried out by using a questionnaire. Informed written consent was obtained from the hospital authority. Analysis of data was finally done with Statistical Package for Social Science program 17 version of computer on the basis of different variables.&#x0D; Result: As ST-segment elevation in lead aVR is a continuous variable, a suitable cut-off for ST- elevation in lead aVR was found out for diagnosing LM and/or triple vessel disease (TVD) using ROC curve. The cut-off value was 0.75 mm which gave us an optimum sensitivity of 88.5% and a specificity of 80% with an area under the curve being 0.892(95% CI = 0.785-1.000), p &lt; 0.001. The area under the curve demonstrated that 89.2% of the LM and/or TVD were correctly diagnosed with ST elevation e” 0.75 mm in lead aVR in patients with non-ST segment elevation acute coronary syndrome. The positive predictive value was commendably high (92%) and negative predictive value was no less (72.7%) with an overall diagnostic accuracy of 86%.&#x0D; Conclusion: From the findings of the study it can be concluded that ST- segment elevation e”0.75 mm in lead aVR in patients of non-ST segment elevation acute coronary syndrome had optimum sensitivity and specificity with an appreciably high overall diagnostic accuracy. The ST- segment elevation e”0.75 mm in lead aVR in patients with non-STE-ACS can differentiate LM and/or triple vessel disease with fair degree of accuracy.&#x0D; University Heart Journal Vol. 14, No. 2, Jul 2018; 71-76

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.

Investigating Nurses’ Knowledge and Performance on the Diagnostic and Therapeutic Application of Lead aVR

Background: The diagnostic and therapeutic uses of lead aVR in coronary artery disease, especially LAD stenosis, are very important in evidence-based nursing. Objectives: The aim of this study was to evaluate the knowledge and performance of nurses in applying lead aVR. Methods: In this descriptive cross-sectional study, 88 nurses working in critical care units were enrolled. The data collection tool was a researcher-made questionnaire, which assessed the knowledge and performance of nurses. The data were analyzed in SPSS software (version 16) using t-test, Kruskal-Wallis test, Mann-Whitney test, and correlation coefficient test. Results: The mean score of nurses’ knowledge was 19.6 ± 5.1 (out of 60) and the majority (53.4%) had an undesirable knowledge level. The mean score of nurses’ performance was 17.3 ± 1.1 (out of 60) and the majority (67%) had an undesirable performance. Moreover, the performance score raised as work experience increased (P = 0.01; r = 0.6). Conclusions: Given the inappropriate knowledge and performance levels of nurses concerning lead aVR application, it is recommended to modify the educational content and implement new educational methods in order to increase the knowledge and performance of nurses in this regard.

75-Year-Old Man With Chest Pain and Dyspnea

75-Year-Old Man With Chest Pain and Dyspnea

PR depression with multi‑lead ST elevation and ST depression in aVR: Is it always acute pericarditis?

The classic electrocardiographic (ECG) manifestation of stage I of acute pericarditis is diffuse ST elevation and PR depression with ST depression in lead aVR. One of the most common conditions, that is often confused with acute pericarditis, is the benign diffuse ST elevation, termed “early repolarization with ST elevation” (ERSTE). ERSTE often presents with diffuse ST elevation in the inferior and anterolateral leads, with or without terminal QRS notching or slurring. As ERSTE often presents with ST elevation in leads I and II, frequently there is concomitant ST depression in lead aVR, similar to the acute pericarditis ECG pattern. Moreover, PR depression in the inferior leads and/or PR elevation in lead aVR is often seen. Here we describe four patients with ERSTE, all had ST elevation in II with either ST elevation or isoelectric ST in lead I and concomitant ST depression in aVR. Two also had PR depression in the inferior leads. None of the patients had clinical symptoms or signs of acute pericarditis. In conclusion, diffuse ST elevation in the inferolateral leads associated with ST depression in aVR and even with PR segment depression is commonly found in ERSTE and should not be considered as pathognomonic of only acute pericarditis.

The prognostic value of positive T wave in lead aVR: A novel marker of adverse cardiac outcomes in peripartum cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is an uncommon complication of pregnancy. Clinical courses of PPCM are markedly heterogeneous. Positive T waves in lead aVR (TaVR) are shown to be associated with adverse cardiac events in several cardiovascular diseases. We aimed to investigate the prevalence and prognostic role of positive TaVR in patients with PPCM. A total of 82 patients (mean age 29.1±6.3years) with the diagnosis of PPCM were enrolled. Presentation electrocardiogram (ECG) was investigated for presence of a positive TaVR. The median follow-up duration was 67.0months. The primary endpoint was defined as composite cardiac events, including cardiac death, arrhythmic events, or persistent left ventricular systolic dysfunction. Patients with positive T wave in lead aVR showed higher rates for persistent left ventricular systolic dysfunction, arrhythmic events, and cardiac death compared to patients without it. In multivariate logistic regression analysis, after adjusting for other confounding factors, the presence of positive TaVR was found to be as an independent and strong predictor of primary composite endpoint (odds ratio 6.21, 95% CI 1.45-26.51; p=0.014). In Kaplan-Meier survival analysis, both primary and secondary endpoints occurred more frequently in the positive TaVR group. Using the cut-off level of 0.25mV, T-wave amplitude in lead aVR predicted primary endpoint with a sensitivity of 100% and specificity of 100%. Positive T wave in lead aVR, as a simple and feasible electrocardiographic marker, seems to be a novel predictor of adverse cardiovascular outcomes in patients with PPCM.

Why complicate an important task? An orderly display of the limb leads in the 12-lead electrocardiogram and its implications for recognition of acute coronary syndrome

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.