Lead aVR, a mostly ignored but very valuable lead in clinical electrocardiography

8jimi8

8jimi8

CFRN
1,792
9
38
http://content.onlinejacc.org/cgi/content/full/38/5/1355

J Am Coll Cardiol, 2001; 38:1355-1356
© 2001 by the American College of Cardiology Foundation
This Article

ACUTE CORONARY SYNDROMES: EDITORIAL COMMENT

Lead aVR, a mostly ignored but very valuable lead in clinical electrocardiography*

Anton P. M. Gorgels, MD, PhD*,a, D. J. M. Engelen, MDa and Hein J. J. Wellens, MD, PhD, FACCa
a Department of Cardiology, University Hospital Maastricht, Maastricht, The Netherlands

* Reprint requests and correspondence: Dr. Anton P. M. Gorgels, Dept. of Cardiology, University Hospital Maastricht, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
t.gorgels@cardio.arm.nl
In this issue of the Journal, Yamaji et al. (1) report on the use of lead aVR in the diagnosis of acute left main coronary artery (LMCA) obstruction. More specifically, the investigators compare the behavior of the ST-segment in lead aVR with lead V1 in that situation. They report that in LMCA occlusion, more ST-segment elevation is present in lead aVR compared to lead V1. They also found a relationship between the amount of ST segment elevation in this lead and mortality. To study the value of these findings in predicting the presence of this condition, they compared the LMCA population with two other acute coronary syndrome populations—that is, with proximal left anterior descending (LAD) or proximal right coronary artery obstruction (RCA). They observed not only a higher incidence of ST
segment elevation in lead aVR in the LMCA group but also more ST-segment elevation. The ST-segment elevation in lead V1 was less in the LMCA group than in the LAD group. The finding of ST-segment elevation in lead aVR V1 distinguished the LMCA group from the LAD group with high values for sensitivity (81%), specificity (80%) and positive predictive accuracy (80%). The ST-segment shift in lead aVR and inferior leads distinguished the LMCA group from the RCA group.

The investigators (1) conclude that ST-segment elevation in lead aVR with less elevation in V1 is an important predictor of acute LMCA obstruction and that the amount of ST-segment elevation is related to patient’s outcome. These findings may be very useful in the early noninvasive recognition of this highly serious disorder, allowing prompt institution of strategies to re-open the left main coronary artery.

However, the data have to be interpreted with some caution before they can be applied in clinical practice. The study, a retrospective one, has to be confirmed in a prospective design. The number of patients was small and was collected over a long period of time. Selection bias could have influenced the enrollment of study patients. For instance, the presence of well-developed collateral circulation could have led to the exclusion of less severe cases. Also, the control groups were derived from an angiographic database, which does not represent the total population with either an LAD or RCA infarction.

Infarctions due to circumflex branch occlusion were not included. Indeed, usually that situation leads to posterolateral and inferior wall ischemia with ST-depression in lead aVR and the mid-precordial leads and ST-elevation in the inferior and the left precordial leads. However, in some cases of circumflex branch occlusion, with ischemia, most pronounced in the posterobasal area, ST-elevation in lead aVR, but not in lead V1, may occur. Also, a control group with an acute coronary syndrome due to three-vessel coronary artery disease was not included, although in this category ST-elevation in lead aVR has been described (2).
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8jimi8

8jimi8

CFRN
1,792
9
38
aVR always throws me off because i always read it as Aortic Valve Replacement.
 
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