ST ELEVATION IN aVR: NOT JUST A SIMPLE ACS!!

Abstract

Introduction

Lead aVR is one of the augmented limb leads in ECG. Traditionally, lead aVR is often overlooked despite its multiple clinical uses. It is oriented to ‘look’ at the right upper side of the heart, thus provide specific information about the right ventricle outflow tract and basal part of the septum. It also displays reciprocal information covered by leads aVL, II, V5 and V6. Recently, ST elevation in aVR with ST-segment depression in multiple other leads was a strong predictor of acute coronary syndrome. However, ST elevation in AVR can be associated with many different conditions, not just ACS!

Case Report

A 31 years old gentleman, ex-smoker with no known medical illness, presented with worsening chest pain for the past one week, describe as heaviness in nature with pain score 9/10. The pain radiate to the back, associated with difficulty in breathing and profuse sweating. ECG showed ST elevation in lead aVR with multiple ST depression at lead II, III, V4-V6. He was initially treated as high risk non-ST elevation MI and was referred to cardiology team for further evaluation and admission.

During review by cardiologist, bedside echo was done which show aortic root dilatation with intimal flap. The patient was then planned for CTA thorax, to rule out aortic dissection. Unfortunately, patient asystole at the emergency department and succumbed to death despite aggressive resuscitation

Discussion and conclusion

ST-segment elevation in aVR reflects global subendocardial ischaemia of left ventricle. In a patient presented with signs and symptoms of acute cardiac ischaemia, ST elevation in aVR often indicates LMCA stenosis/occlusion, proximal LAD occlusion and severe triple vessel disease. However, emergency physician must broaden their differentials, as it is associated with many other different conditions. Failure to identify the correct diagnosis might lead to morbidity and mortality.