ST-segment Depression In Lead aVR Research Articles

Culprit Arteries in Patients with Inferior Wall Myocardial Infarction (IWMI) With St Segment Depression in Lead AVR

ACS is an imbalance between the myocardial oxygen demand and consumption of oxygen by the heart. While coronary plaque rupture, which results in STEMI, is almost always the cause of this mismatch development of thrombus blocking a coronary artery. Objective: To determine the frequency of culprit arteries in patients with inferior wall myocardial infarction (IWMI) with ST Segment depression in Lead AVR. Methods: This cross sectional study was conducted at Department of Adult Cardiology, NICVD, Karachi, Pakistan from November 4, 2020 to May 3, 2021. All patients who fulfilled the inclusion criteria were enrolled and consent was taken. All patients were initially stabilized and then were prepared for coronary angiography. Interpretation of coronary angiogram was done to assess the culprit arteries i.e. LCX, RCA. Data were collected in proforma. Results. Out of 317 patients, 233 (73.5%) were male while 84 (26.5%) were female with mean age of 51.4±12.4 years. Left circumflex coronary artery was found in 184 (58%) patients. Right coronary artery was found in 133 (42%) patients. Conclusions: This study concludes that LCX artery is more likely to be culprit in patients with inferior wall myocardial infarction and ST-segment depression in lead AVR. STEMI patients with IWMI should be worked up for the presence of culprit arteries to ensure adequate treatment

The Relationship Between ST-Segment Depression in Lead aVR and Coronary Microvascular Function in Acute Inferior Myocardial Infarction

Aim: The aim of this study was to investigate the relationship between ST-segment depression in the aVR lead and coronary microvascular function in acute inferior myocardial infarction undergoing primary percutaneous intervention.
 Methods: 287 patients with inferior myocardial infarction confirmed by coronary angiography were divided into two groups with and without ST-segment depression in lead aVR ≥ 0.1 mV on the 12 lead ECG. Electrocardiographic recordings were made for the evaluation of ST-segment resolution before and after primary PCI. Angiographic assessment in the infarct-related artery was performed by using the myocardial blush grade and thrombolysis in myocardial infarction flow. 
 Results: Overall, 51 of 287 patients had ST-segment depression in lead aVR. The number of patients with RCA-induced infarction was higher in the group with ST-segment depression in lead aVR. RCA involvement was present in 44 patients. Peak troponin was higher in the group with ST-segment depression in lead aVR compare to the other group (P <0.001). The MBG was more impaired, and the STR was less regressed in patients with ST depression in lead aVR (p<0,001). The ejection fraction of patients with ST-segment depression in lead aVR was lower.
 Conclusion: We found that ST-segment depression in lead aVR was associated with impaired myocardial perfusion in patients with inferior myocardial infarction.

A Study of the ST Changes in the aVR Lead on 12-Lead ECG to Identify Infarct - Related Artery (IRA) in Patients With Acute Inferior Wall Myocardial Infarction

BACKGROUND: Lead avR is a valuable but mostly ignored lead in clinical electrocardiography. Recently, ST-segment depression in lead aVR during an inferior wall myocardial infarction has been suggested as a predictor of LCX artery involvement.
 METHODS: This study was a single centre cross sectional observational study done in BPKIHS, Dharan from February 2018 to January 2020. Patients presenting to the OPD or emergency room of BPKIHS diagnosed as acute inferior wall myocardial infarction based on clinical symptoms, ECG and/or Cardiac tropinin I levels, and planned for coronary angiography, meeting the inclusion and exclusion criterias were included.
 RESULTS: Among 134 cases, male:female ratio was 1.3:1. Overall, 38 patients (28.4%) were found to have aVR depression and 96 patients (71.6%) were without aVR depression. The culprit artery was found to be the right coronary artery in 95 patients (70.9%), the LCx in 39 patients (29.1%). The sensitivity and specificity of ST-segment depression in lead aVR for LCx as the culprit artery were 92.3% and 97.9% respectively. Positive predictive and Negative predictive value for LCx as the culprit arteries were 94.74% and 96.87%. The sensitivity, specificity, positive predictive value and negative predictive value for RCA as the culprit artery were 97.89%, 92.3%, 96.89% and 94.73% respectively.
 CONCLUSION: Significant ST depression in aVR is associated with a higher specificity and good sensitivity for LCX lesions, the ST changes in this lead should be carefully examined in all patients who are suspected of having inferior wall myocardial infarction.

PR depression with multilead ST elevation and ST depression in aVR by left circumflex artery occlusion: How to differentiate from acute pericarditis

PR‐segment depression with multilead ST‐segment elevation and ST‐segment depression in lead aVR are classic ECG manifestation of acute pericarditis. We present a patient, where the etiology of these ECG features was acute ST‐elevation myocardial infarction due to left circumflex artery occlusion. To avoid misdiagnosis, unnecessary examinations, and inappropriate therapeutic decisions, the possibility of ST‐segment elevation myocardial infarction should be kept in mind even when ECG changes typical for pericarditis are encountered in chest pain patients. Findings of QRS widening and QT interval shortening in leads with ST‐segment elevation could help to differentiate acute ST‐segment elevation myocardial infarction from acute pericarditis.

Utility of aVR electrocardiogram lead for identifying the culprit lesion in patient with acute coronary syndrome

Background: The lead aVR is neglected electrocardiography (ECG) lead while interpreting various cardiac diseases including coronary artery disease (CAD). The aVR lead is a potentially useful tool in ECG in diagnosing and managing patients with CAD. Aim and Objectives: The aim is to study the usefulness of ECG in localizing the culprit vessel by coronary angiogram (CAG) in patients with the acute coronary syndrome (ACS) and to find the relation of ECG findings, with regional wall motion abnormality (RWMA) and CAG profile. \Materials and Methods: This was a cross-sectional observational study done on patients admitted with the diagnosis of ACS. A total of 54 patients were included in this study satisfying the inclusion criteria presented with ACS. Results: A total of 54 patients (males: 55.7% and females: 46.3%) were enrolled fulfilling inclusion criteria of the study (male: 59.72 [±10.59], female: 55.24 [±11.93]). A total 59.36% of patients had resulting RWMA. About 33.33% of patients had single-vessel disease, 24.07% had double-vessel disease , and 18.52% had triple-vessel disease (TVD) with P = 0.081. A total 79.62% of patients ECG could able to diagnose CAD. About 100% of patients with proximal left anterior descending (LAD) lesion 85.71% with LMCA, 40% with TVD had ST elevation in aVR lead. About 66.67% of patients with the right coronary artery (RCA) and 50% with left circumflex infarction (LCx) lesion had ST depression in aVR lead. About 59.36% had RWMA on echocardiogram. Conclusions: The presence of ST elevation in aVR indicates a culprit lesion in the proximal segment of LAD or LMCA. The absence ST elevation in aVR excludes the left main coronary artery as the underlying cause in the context of anterior wall ST-elevation myocardial infarction (STEMI). ST elevation in aVR is valuable for distinguishing proximal from distal lesions in the LAD in anterior wall STEMI. ST-segment depression in lead aVR is valuable for differentiating RCA from those with LCx in the inferior STEMI. Echocardiography findings aid triage for the management of the patient with ACS.

ST-SEGMENT DEPRESSION IN LEAD AVR PREDICTS 30-DAY ADVERSE OUTCOMES IN PATIENTS WITH INFERIOR ACUTE MYOCARDIAL INFARCTION

During inferior acute myocardial infarction (IMI), ST-segment depression in lead aVR (ST↓aVR) can be caused by a reciprocal change of ST-segment elevation in lead -aVR facing the apical wall, suggesting a larger area at risk. We examined the prognostic implication of ST↓aVR in patients with

Significance of lead aVR in acute coronary syndrome.

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. However, recent investigations have shown that an analysis of ST-segment shift in lead aVR provides useful information on the coronary angiographic anatomy and risk stratification in ACS. ST-segment elevation in lead aVR can be caused by (1) transmural ischemia in the basal part of the interventricular septum caused by impaired coronary blood flow of the first major branch originating from the left anterior descending coronary artery; (2) transmural ischemia in the right ventricular outflow tract caused by impaired coronary blood flow of the large conal branch originating from the right coronary artery; and (3) reciprocal changes opposite to ischemic or non-ischemic ST-segment depression in the lateral limb and precordial leads. On the other hand, ST-segment depression in lead aVR can be caused by transmural ischemia in the inferolateral and apical regions. It has been recently shown that an analysis of T wave in lead aVR also provides useful prognostic information in the general population and patients with prior myocardial infarction. Cardiologists should pay more attention to the tracing of lead aVR when interpreting the 12-lead ECG in clinical practice.

ST-segment deviation pattern of takotsubo cardiomyopathy similar to acute pericarditis: Diffuse ST-segment elevation

BackgroundPossible similarities or differences in the ST- and PR-segment deviations in the electrocardiogram of takotsubo cardiomyopathy (TTC) and acute pericarditis (AP) are not well defined. MethodsWe compared different parameters of the admission electrocardiogram in eight patients with TTC and eight patients with AP with ST-segment elevation in the acute phase. ResultsWe found significant differences in the maximal magnitude of the T wave in the precordial leads, but not in the ST- and PR-segment deviation patterns between the two patient groups. All the patients in the two groups showed consistent ST-segment depression in lead aVR and absence of ST-segment elevation in lead V1. ConclusionsThe ST- and PR-segment deviation patterns in TTC are similar to that of AP, namely diffuse ST-segment elevations with reciprocal changes in aVR and V1 and PR-segment elevation in aVR accompanied by PR-segment depression in the inferior leads, possibly indicating that TTC has ECG characteristics of circumferential subepicardial ischemia in the acute phase.

Abstract 8952: ST-Segment Depression in Lead aVR Predicts In-Hospital Adverse Outcomes in Patients With Inferior Wall Acute Myocardial Infarction

Introduction: During inferior wall acute myocardial infarction (IWMI), lead aVR is frequently ignored. However, ST-segment depression in lead aVR (ST↓aVR) during IWMI might represent a reciprocal change in response to an opposite vector resulting from ST-segment elevation in the apical region, suggesting a larger area at risk. Hypothesis: We assessed the hypothesis that ST↓aVR can provide important prognostic information in patients with reperfused IWMI. Methods: We studied 268 patients with a first IWMI who had TIMI 3 flow of the right coronary artery or left circumflex coronary artery after fibrinolysis or primary percutaneous coronary intervention within 6 h after symptom onset. Patients were divided into the 3 groups according to the degree of ST↓aVR on admission ECG: G-A, 122 patients with no ST↓aVR; G-B, 95 patients with ST↓aVR ≤1.0 mm; and G-C, 51 patients with ST↓aVR >1.0 mm. The perfusion territory of the culprit artery was assessed on the basis of the angiographic distribution score. Impaired myocardial reperfusion was defined as myocardial blush grade 0/1 on the final angiogram. Results: There were no differences in age, coronary risk factors, time to admission, reperfusion therapy, culprit artery, or final TIMI flow grade among the 3 groups. In G-A, G-B, and G-C, the sum of ST-segment elevation in leads II, III, aVF and V5-6 on admission ECG was 4±4, 9±5, and 17±7 mm (p<0.01); the angiographic distribution score was 0.5±0.2, 0.6±0.2, and 0.7±0.1 (p<0.01); peak creatine kinase level was 2225±1515, 3150±1792, and 4911±2238 mU/ml (p<0.01); and the frequencies of impaired myocardial reperfusion was 4%, 18%, and 71% (p<0.01); the combined outcome of in-hospital death, reinfarction, or congestive heart failure was 2%, 7%, and 14% (p<0.01), respectively. Multivariate analysis showed that as compared with no ST↓aVR, the odds ratios (95% CI) for in-hospital adverse events associated with ST↓aVR ≤1.0 mm and ST↓aVR >1.0 mm were 1.49 (0.64-3.39; p=0.15) and 2.01 (1.18-4.51; p<0.05), respectively. Conclusions: In patients with reperfused IWMI, greater ST↓aVR on admission ECG is associated with a larger area at risk, impaired myocardial reperfusion, and a larger infarct size. ST↓aVR >1.0 mm is an independent predictor of in-hospital adverse outcomes.

Abstract 4862: ST-Segment Depression in Lead aVR: A Useful Predictor of Impaired Myocardial Reperfusion in Patients With Anterolateral ST-Segment Elevation Acute Myocardial Infarction

Background: ST-segment depression in lead aVR during ST-segment elevation acute myocardial infarction (STEMI) theoretically represents a reciprocal change in response to an opposite vector resulting from ST-segment elevation in the apical and inferolateral walls. We hypothesized that ST-segment depression in lead aVR during anterolateral STEMI is associated with less successful myocardial reperfusion, because of more extensive area at risk. Methods: We studied 301 patients with a first anterolateral STEMI who underwent coronary recanalization (TIMI grade 3 flow) by fibrinolysis or percutaneous coronary intervention within 6 h after symptom onset. Patients were divided into the 3 groups according to ST-segment deviation in lead aVR on admission ECG: group A, 71 patients with ST-segment elevation of ≥ 0.5 mm; group B, 131 patients without ST-segment deviation; and group C, 99 patients with ST-segment depression of ≥ 0.5 mm. Myocardial blush grade was assessed immediately after recanalization. Results: There were no differences in age, sex, coronary risk factors, time from symptom onset to admission, or multivessel disease among the 3 groups. In groups A, B, and C, the incidence of Killip class ≥ 2 was 6%, 6%, and 15% (p=0.03); the sum of ST-segment elevation in leads I, aVL, and V1– 6 was 20±11, 23±9, and 33±14 mm (p<0.01); the rates of initial TIMI grade 0 or 1 flow was 56%, 70%, and 78% (p=0.01); good collateral circulation was 43%, 39%, and 22% (p=0.03); impaired myocardial reperfusion (defined as myocardial blush grade 0 or 1) was 14%, 23%, and 65% (p<0.01); peak creatine kinase level was 3432±1995, 4045±2144, and 5986±2550 mU/ml (p<0.01); and predischarge left ventricular ejection fraction was 56±13%, 51±11%, 44±12% (p<0.01), respectively. Multivariate analysis showed that ST-segment depression in lead aVR was an independent predictor of impaired myocardial reperfusion (odds ratio 3.31, 95% CI 1.98 to 5.52, p<0.001); but sum of ST-segment elevation in leads I, aVL, and V1– 6 was not. Conclusions: In patients with anterolateral STEMI, ST-segment depression in lead aVR on admission ECG is associated with less successful myocardial reperfusion and larger infarct. Assessment of ST-segment deviation in lead aVR is useful for acute risk stratification.

ST-segment depression in aVR as a predictor of culprit artery and infarct size in acute inferior wall ST-segment elevation myocardial infarction

Background ST-segment depression in lead aVR in acute inferior wall ST-segment elevation myocardial infarction (STEMI) has recently been suggested as a predictor of left circumflex (LCx) artery involvement. The purpose of this study is to evaluate the clinical significance of aVR depression during inferior wall STEMI. Methods This study included 106 consecutive patients who presented with inferior wall STEMI and underwent urgent coronary angiogram. Clinical and angiographic findings were compared between patients with and without aVR depression ≥0.1 mV. Results The sensitivity and specificity of aVR depression as a predictor of LCx infarction were 53% and 86%, respectively. In patients with right coronary artery infarction, aVR depression was associated with increased cardiac enzymes and the involvement of a large posterolateral branch, which may explain the larger infarction. Conclusions ST-segment depression in lead aVR in inferior wall STEMI predicts LCx infarction or larger RCA infarction involving a large posterolateral branch.

ST-Segment Depression in Lead aVR: A Useful Predictor of Impaired Myocardial Reperfusion in Patients With Inferior Acute Myocardial Infarction

During inferior acute myocardial infarction (AMI), the ECG lead aVR is frequently ignored, and therefore its clinical significance remains unclear. We examined the relation between ST-segment deviation seen in lead aVR on ECGs obtained at hospital admission and myocardial reperfusion in patients who have experienced recanalized inferior AMIs.Retrospective study.A total of 225 patients with inferior AMIs in whom Thrombolysis in Myocardial Infarction grade 3 flow was achieved within 6 h after symptom onset.Patients were classified as follows according to ST-segment deviation in lead aVR on an ECG obtained at hospital admission: group A, 103 patients with no ST-segment depression; group B, 80 patients with ST-segment depression of < or = 1.0 mm; and group C, 42 patients with ST-segment depression of > 1.0 mm. There were no differences in time from symptom onset to hospital admission or in the culprit lesion among the three groups. The degree of ST-segment elevation in leads II, III, aVF, V5, or V6, the degree of ST-segment depression in leads V1 to V4, and the sum of ST-segment deviation in these leads were lowest in group A and highest in group C. In groups A, B, and C, the incidence of impaired myocardial reperfusion, defined as myocardial blush grade 0/1, was 2%, 23%, and 67%, respectively (p < 0.001). The sensitivity and negative predictive values of ST-segment depression in lead aVR for impaired myocardial reperfusion were higher than those based on other ECG variables. Multivariate analysis showed that the degree of ST-segment depression in lead aVR was an independent predictor of impaired myocardial reperfusion (odds ratio 8.41; 95% confidence interval, 2.96 to 23.9; p < 0.001).We conclude that the degree of ST-segment depression in lead aVR is a useful predictor of impaired myocardial reperfusion in patients who have experienced inferior AMIs.

Clinical utility of ST-segment depression in lead AVR in acute myocardial infarction

The present study evaluated the prevalence and significance of ST-segment depression (STD) in lead aVR on the admission 12-lead electrocardiogram in 307 consecutive patients with an acute myocardial infarction (AMI) with ST-segment elevation. STD in aVR was present in a significantly higher proportion of patients with inferior/posterior AMIs. Within inferior/posterior AMIs those with STD in aVR had significantly more concomitant STD in V1, V2, V3 and more concomitant STesegment elevation in V5, V6 and right precordial leads. These data suggests that STD in aVR may point to a coronary artery with a large area of supply as the culprit vessel responsible for the AMI.

ECG Discrimination Between Right and Left Circumflex Coronary Arterial Occlusion in Patients With Acute Inferior Myocardial Infarction: Value of Old Criteria and Use of Lead aVR

Prior studies have proposed several ECG criteria for identifying the culprit artery in patients with acute inferior myocardial infarction (MI). We applied each criterion to our patients to assess its utility. In doing so, we discovered a previously unreported, but highly useful, criterion utilizing lead aVR. Retrospective review. Thirty consecutive patients with symptoms of acute MI, ST-segment elevation in the inferior ECG leads, an appropriate rise and fall of creatine kinase and troponin I levels, and coronary arteriography within 7 days of the onset of symptoms. The ECG recorded within 24 h of the onset of symptoms that had the most prominent ST-segment changes was analyzed. In the 12 standard leads and in lead V(4)R, ST-segment elevation or depression was measured 0.06 s after the J point. Four previously described criteria were useful in identifying the right coronary artery (RCA) or the left circumflex coronary artery (LCX) as the culprit: ST-segment elevation in lead I, ST-segment more or less elevated in lead II than in lead III, ST-segment elevation >or= 0.5 mm in lead V(4)R, and various combinations of ST-segment elevation or depression in leads V(1) and V(2). A new criterion was found to be at least as useful as any previously described: the presence and amount of ST-segment depression in lead aVR. At least five different ST-segment criteria help to identify the RCA or the LCX as the culprit artery in patients with acute inferior MI. One of these, the amount of ST-segment depression in lead aVR, has not been reported previously and needs validation in a larger study.

ST-segment depression in lead aVR predicts predischarge left ventricular dysfunction in patients with reperfused anterior acute myocardial infarction with anterolateral ST-segment elevation

Background Patients with an anterolateral acute myocardial infarction (AMI) have a worse prognosis, and those with additional inferolateral wall involvement might be higher risk because of more extensive area at risk. Lead –aVR obtained by inversion of images in lead aVR has been reported to provide useful information for inferolateral lesion. Methods We examined the relation between ST-segment deviation in lead aVR on admission electrocardiogram (ECG) and left ventricular function in 105 patients with an anterolateral AMI undergoing successful reperfusion ≤6 hours after onset. Patients were classified according to ST-segment deviation in lead aVR on admission ECG: group A, 23 patients with ST elevation of ≥0.5 mm; group B, 47 patients without ST deviation; and group C, 35 patients with ST depression of ≥0.5 mm. Results There were no differences among the 3 groups in age, sex, or site of the culprit lesion. In groups A, B, and C, the peak creatine kinase level was 3661 ± 1428, 4440 ± 1889, and 6959 ± 2712 mU/mL, and the left ventricular ejection fraction (LVEF) measured by predischarge left ventriculography was 54% ± 9%, 48% ± 7%, and 37% ± 9%, respectively(P <.01). During hospitalization, congestive heart failure occurred more frequently in group C than in groups A or B (P <.05). ST-segment depression in lead aVR had a higher predictive accuracy than other ECG findings in identifying patients with predischarge LVEF ≤35%. Conclusions We conclude that in patients with an anterolateral AMI, ST-segment depression in lead aVR on admission ECG is useful for predicting larger infarct and left ventricular dysfunction despite successful reperfusion. (Am Heart J 2001;142:51-7.)