ST-segment Elevation In Lead aVR Research Articles

Diagnostic test accuracy of life-threatening electrocardiographic findings (ST-elevation myocardial infarction equivalents) for acute coronary syndrome after out-of-hospital cardiac arrest without ST-segment elevation

AimLife-threatening electrocardiographic (ECG) findings aid in the diagnosis of acute coronary syndrome (ACS), which has not been well-evaluated in patients with out-of-hospital cardiac arrest (OHCA). This study aimed to evaluate the diagnostic test accuracy (DTA) of ST-elevation myocardial infarction (STEMI) equivalents following the return of spontaneous circulation (ROSC) in patients with OHCA to identify patients with ACS. MethodsUsing the database of the Comprehensive Registry of In-Hospital Intensive Care for OHCA Survival study from 2012 to 2017, patients aged ≥18 years with non-traumatic OHCA and ventricular fibrillation or pulseless ventricular tachycardia on the arrival of emergency medical service personnel or arrival at the emergency department, who achieved ROSC, were included. Patients without ST-segment elevation or complete left bundle branch block on ECG and those who did not undergo ECG or coronary angiography, were excluded from the study. We evaluated the DTA of STEMI equivalents for the diagnosis of ACS: isolated T-wave inversion, ST-segment depression, Wellens’ signs, and ST-segment elevation in lead aVR. ResultsIsolated T-wave inversion and Wellens’ signs had high specificity for ACS with 0.95 (95% confidence interval [CI], 0.87–0.99) and 0.92 (95% CI, 0.82–0.97), respectively, but their positive likelihood ratios were low, with a wide range of 95% CI: 1.89 (95% CI, 0.51–7.02) and 0.81 (95% CI, 0.25–2.68), respectively. ConclusionThe DTA of STEMI equivalents for the diagnosis of ACS was low among patients with OHCA. Further investigation considering the measurement timing of the ECG after ROSC is required.

403 ECG EXERCISE STRESS TEST PREDICTORS OF LEFT MAIN CORONARY ARTERY DISEASE

Abstract Background Left main coronary artery disease (LMCAD) heavily affects prognosis of patients with suspected CAD. Thus, its identification/exclusion is an important step in the assessment of these patients. Although being the gold standard to identify LMCAD, invasive coronary angiography (ICA) is burdened by some risks, while coronary computed tomography angiography (CCTA) has still limited availability, quite high costs and associated radiologic risks. In the past decades, several studies demonstrated the utility of ECG exercise stress test (EST) for the identification of LM disease in patients with suspected CAD. However, the pre-test probability of CAD of subjects undergoing EST has significantly changed in the last decades. Accordingly, in this study we aimed to assess the predictive value of EST for the presence/absence of LMCAD in a contemporary population of patients with suspected CAD. Methods We retrospectively enrolled 495 consecutive patients, referred to our Center between years 2018 and 2021 because of suspected CAD, who underwent both an EST (standard treadmill Bruce protocol) and ICA (within 12 months of the EST). Patients with a history of coronary artery bypass surgery were excluded. Results Overall, 24 patients (4.8%) were found to have LMCAD at ICA. Among clinical variables, only male gender (p=0.025) and smoking (p=0.003) were associated with LMCAD. A number of ECG leads with EST-induced ST-segment depression (STD) ≥5 and a maximal STD ≥2 mm were more frequently found in patients with, compared to those without LMCAD (29.2 vs 9.8%, p=0.003; and 58.3 vs 24.8%, p<0.001, respectively). No other EST variable was associated with LMCAD, including ST-segment elevation in lead aVR (4.2 vs. 2.6% in the 2 groups, respectively, p=0.63). On the other hand, among the 206 patients (41.6% of the population) who achieved 85% of maximal heart rate predicted for age and had ST-segment depression < 2mm, LMCAD was present in 1.9% only. Conclusions Our data indicate that EST continues to be a valuable tool for predicting the presence/absence of LMCAD in contemporary populations of patients with suspected coronary artery disease.

Repeated Syncope During Exercise as a Result of Anomalous Origin of Left Coronary Artery With Intramural Aortic Course in a Teenage Boy

Anomalous origin of the left coronary artery from the opposite sinus of Valsalva with an intramural aortic course (L-ACAOS-IM) can cause syncope, sometimes as a prodrome of lethal events, including sudden cardiac death, in young athletes. The detailed mechanism of syncope in patients with L-ACAOS-IM is still unclear. This case report describes a 17-year-old boy who presented to the hospital because of syncope following chest pain with increasing frequency during exercise, such as playing soccer and running. In a treadmill exercise test, a decrease in blood pressure was seen (from 99/56 mm Hg to 68/38 mm Hg); chest pain and faintness accompanied by ST-segment elevation in lead aVR and ST-segment depression at other leads on electrocardiography were noted. These findings and symptoms disappeared spontaneously within a few minutes while clinicians prepared for emergency medications. Coronary computed tomography angiography (CCTA) showed that the origin of the left coronary artery (LCA) was the opposite sinus of Valsalva, and the course of the LCA was through the aortic wall toward the left coronary sinus. He was diagnosed with L-ACAOS-IM. After surgical treatment by unroofing the intramural part of the LCA and reconstructing a neo-ostium, he no longer experienced syncope during exercise. This case suggests that low cardiac output caused by myocardial ischemia, not life-threatening arrythmia, is a main mechanism of syncope in patients with L-ACAOS-IM. Consideration should be given to performing CCTA before an exercise stress test for young patients with syncope and chest pain to avoid the risk of severe myocardial ischemia.

Multiple Anastomotic Dehiscences After the Bentall Procedure for Aortitis Syndrome.

A 53-year-old man with aortitis was transferred to the current hospital for severe cardiogenic shock. He had undergone the Bentall procedure for annulo-aortic ectasia at the age of 30 years and had received steroid therapy following the diagnosis of aortitis. The preoperative 12-lead electrocardiogram showed ST-segment elevation in lead aVR with diffuse ST-segment depression, suggesting coronary malperfusion. Computed tomography (CT) images demonstrated a retrosternal super-giant pseudoaneurysm (Figure 1A-C) and dehiscence of the distal end of the composite graft from the native aorta (Figure 1B).

Shark Fin Electrocardiogram in the Intensive Care Unit.

Shark Fin Electrocardiogram in the Intensive Care Unit.

The Study of Associations of ECG Changes in Lead aVR and Lead V6 with Acute Coronary Syndrome (ACS)

BACKGROUND
 The ECG (Electrocardiogram) lead aVR gives reciprocal data for the aVL, II, V5, and V6 leads. It is frequently ignored, even while reviewing complicated ECGs. The purpose of the study was to evaluate the associations of ECG changes in Lead aVR and Lead V6 with acute coronary syndrome (ACS) and coronary complexity as measured by CAG (coronary angiography) in patients with the ACS.
 METHODS
 This was a prospective Hospital-based observational study. A sample size of 80 patients was being used and a study was done on patients admitted to Mahatma Gandhi Medical College & Hospital, Jaipur with ACS, for 18 months, as well as on those who met the inclusion criteria.
 RESULTS
 Of 80 patients enrolled with ACS, the mean age was 60.3500 ± 14.8717 (Mean ± SD). The proportion of patients (72.5 percent) had a history of hypertension, and the prevalence of diabetes in the population was found to be significant. The mean ST elevation in lead aVR of patients was 1.4500 ± 0.6779. The mean ST depression in Lead V6 (Mean ± SD) of patients was 2.1519 ± 0.6063. The mean ST depression in corresponding leads (Mean ± SD) was 2.0375± 0.6303 in patients of ACS. In CAG, 27 (33.8 %) patients had TVD (triple vessel disease), 20 (25.0 %) had DVD (double vessel disease) and 22 (27.5 %) patients had SVD (single-vessel disease). The majority of patients, 46 (57.5 %) had angioplasty, and the distribution of coronary artery bypass graft (CABG) outcomes in the overall population was determined to be significant. ECG changes in leads aVR and V6 correlate with age, lead V1, corresponding leads, troponin levels, and Timi Score (Thrombolysis in Myocardial Infarction). There is a positive association in both leads aVR and V6, and the changes occur concurrently in terms of many parameters, indicating the necessity for additional investigation. The outcomes of our investigation were consistent with the findings of ST-T changes in lead aVR and lead V6.
 CONCLUSIONS
 ECG changes in leads aVR and V6 are associated with poorer prognosis in ACS. Widespread ST-segment depression and ST-segment elevation in lead aVR during episodes of chest pain may represent diffuse subendocardial ischemia caused by severe coronary artery disease (CAD). Further, when interpreting the 12-lead ECG in clinical practice, physicians should give due consideration to the tracing of lead aVR and lead V6 as it can help in identifying the patients who need more aggressive management.

Is It ST-Segment-Elevation Myocardial Infarction?

A 76-year-old man presented with acute-onset chest pain and dyspnea. He had a history of coronary artery disease, ischemic cardiomyopathy (left ventricular ejection fraction, 25%), recent non-ST-segment-elevation myocardial infarction (NSTEMI), and stenting of the left anterior descending coronary artery (LAD) one month before the current presentation. Soon thereafter, he underwent stenting of the left main coronary artery (LMCA), obtuse marginal branch (OMB), and left circumflex coronary artery. His chest pain subsided soon after arrival at the emergency department. His cardiac troponin I level was 22 ng/mL (normal level, <0.03 ng/mL), and his brain natriuretic peptide level was 841 pg/mL (normal level, <100 pg/mL). Figure 1 shows his electrocardiogram (ECG).What is the diagnosis?C) STEMI due to first OMB or ramus intermedius occlusionThe ECG shows sinus rhythm, mild ST-segment elevation (STE) with T-wave inversion in lead aVL, ST-segment depression with positive T waves in leads II, III, aVF, and V3 through V6, and an isoelectric ST segment in leads I and V1 through V2. The Fourth Universal Definition of Myocardial Infarction1 says, “More profound ST-segment shifts or T-wave inversions involving multiple leads/territories are associated with a greater degree of myocardial ischaemia, and a worse prognosis. For example, ST-segment depression ≥1 mm in 6 leads, which may be associated with STE in lead aVR or lead V1 and hemodynamic compromise, is suggestive evidence of multivessel disease or left main disease” (eliminating answer A). This is considered a high-risk ECG pattern for which invasive intervention within 2 hours is recommended, in accordance with the 2020 European Society of Cardiology guidelines for managing acute coronary syndromes without persistent STE.2 Our patient's ECG shows ST-segment depression in 7 leads but no significant STE in lead aVR or V1. In contrast, STE with negative T waves is seen in lead aVL.Patients with a nonischemic early repolarization pattern can have STE in lead aVL. However, the T waves are usually positive, and there is often a J-point notch. The pattern here suggests a reperfused or more advanced stage of STEMI,3 and the patient's clinical presentation (symptom resolution after hospital arrival) supports this diagnosis.New STE in 2 contiguous leads is necessary for the diagnosis of STEMI.1 However, this is an epidemiologic (not pathophysiologic) criterion, to minimize false-positive diagnosis. Acutely occluded arterial branches may cause STE in only one lead with diffuse ST-segment depression.4 The STE in leads aVL and V2 through V5 is caused by LAD occlusion proximal to the first diagonal branch (eliminating answer B),4 and STE in leads aVL and V2 without STE in leads V3 through V5 suggests an occluded first diagonal branch. The ST-segment depression in the anterolateral and inferior leads is incompatible with the typical presentation of takotsubo cardiomyopathy (answer D). The STE in lead aVL, incompatible with ischemic cardiomyopathy (answer E), is accompanied by ST-segment depression in lead V2, suggesting obstruction of the first OMB. Our patient had an isoelectric ST segment in lead V2, so the differential diagnosis is an occluded OMB or ramus intermedius.4 A coronary angiogram on the second day of admission showed subacute thrombotic occlusion of the first OMB (Fig. 2, arrow), and stenting restored patent flow.Disclosures: NoneFunding/support: None

Association of aVR ST-elevation with outcomes in patients with acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Evaluation of the lead aVR in the diagnosis of acute coronary syndrome has been neglected before.1 However, there is evidence that an ST segment elevation in that lead correlates to a significant coronary artery disease.1,2 This study aimed to determine the association with clinical outcomes of an aVR ST elevation in patients with acute coronary syndrome. Purpose Identify patients who are at high risk on presentation at the emergency department. Methods This was a retrospective cohort study. Patients aged 19 years and above who were diagnosed with either unstable angina, non ST-elevation MI or ST elevation MI were eligible subjects. The medical records of patients in a tertiary referral government hospital were evaluated. The independent variable was the lead aVR ST elevation, while the primary outcome was the in-hospital mortality. Descriptive statistics was used to summarise the demographic and clinical characteristics of the patients. Frequency and proportion was used for categorical variables, median and inter quartile range for non-normally distributed continuous variables, and mean and standard deviation for normally distributed continuous variables. Independent Sample T-test and Fisher’s Exact test was used to determine the difference of mean and frequency, respectively, between patients with and without in-hospital outcomes. Odds ratio and corresponding 95% confidence intervals from binary logistic regression was computed to determine significant predictors of in-hospital outcomes. Missing variables was neither replaced nor estimated. Null hypotheses was rejected at 0.05α-level of significance. Results There were a total of 108 patients included. Most subjects were males and aged 57-62 years old. Majority had NSTE-ACS and STEMI at presentation. Lead aVR ST elevation group had an OR of 17 (95% CI 4.38-67.50 and p < 0.001) for in-hospital mortality, compared to the group without. On coronary angiogram, these patients had either a significant left main coronary artery disease or a multi-vessel coronary artery disease. Conclusion The presence of a lead aVR ST segment elevation in patients with acute coronary syndrome at presentation in the emergency department is associated with increased in-hospital mortality.

The Added Value of ST-Elevation in Lead aVR to Clinical TIMI Score in Predicting the Angiographic Severity of Coronary Artery Disease in Patients with Non ST-Elevation Myocardial Infarction

Abstract Background Atherosclerosis is the ongoing process of plaque formation involving primarily the intima of large and medium-sized arteries. The condition progresses relentlessly throughout a person’s lifetime, before finally manifesting itself as an acute ischemic event. TIMI score is a tool of 7 points for patients with NSTE-ACS to detect the risk according to the score. The term acute coronary syndrome (ACS) includes unstable angina (UA), non STsegment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Aim To investigate the added value of the presence of ST-segment elevation in lead avR on admission electrocardiogram to the (TIMI) clinical scoring system in predicting the angiographic severity of coronary artery disease in patients admitted with NSTE-ACS. Patients and Methods 150 patients with Non ST-segment elevation acute coronary syndrome was included from Cardiology Department, Ain Shams University Hospital, Cairo, Egypt. Results From those patients, 137 patients (91.3%) diagnosed by coronary angiography to have significant CAD and 93 patients (62%) had ST-Elevation in lead aVR . These 137 patients were divided into 3 groups according to TIMI risk score to 16 patients (10.6%) had low risk score, 63 patients (42.0%) had intermediate risk & lastly 58 patients (38.7%) had high risk score. . Although being useful in prediction of multi-vessel & LM involvement among high risk group, TIMI score failed to predict the same in intermediate & low risk groups where multi-vessel involvement was found in 46 patients (30.6%) & 7 patients (4.6%) of intermediate & low risk groups respectively. Also LM involvement was found in 15 patients (10%) & 2 patients (1.3%) of intermediate & low risk groups respectively. Conclusion ST-segment elevation (STE) in lead avR had an adding predicting value in NSTEACS patients especially those with low to intermediate TIMI score. Adding the value of STE in lead aVR to TIMI risk score may improve the early stratification & management of those patients at high risk coronary artery disease, with subsequent impact on morbidity & mortality.

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).

EKG-gyöngyszem: acut coronaria szindrómát utánzó sinuscsomó-betegség – az aVR-jel

The aVR-sign can indicate left main or multivessel coronary disease, but the sign is not STEMI eqvivalent and is not a sensitive sign for coronary disese. The following case is an example of this. An 89-year-old woman was admitted with chest pain, atrial fibrillation and multiple lead ST-segment depression but ST-segment elevation in lead aVR. The aVR-sign indicated urgent angiography with negative result. A spontaneous sinus conversion was observed with repolarization normalisation. Later the ECG demonstrated SA-blocks, and sinus arrest. Sick sinus syndrome was diagnosed and the patient was treated with pacemaker and oral anticoagulant. Orv Hetil. 2020; 161(11): 434-436.

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.

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

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

Value of ST-segment elevation in lead aVR in non ST elevation myocardial infarction/unstable angina in predicting disease extent, severity and outcomes at 3 months

Value of ST-segment elevation in lead aVR in non ST elevation myocardial infarction/unstable angina in predicting disease extent, severity and outcomes at 3 months