Lead aVL on electrocardiogram: emerging as important lead in early diagnosis of myocardial infarction?

Hassen, Getaw Worku; Talebi, Soheila; Fernaine, George; Kalantari, Hossein

doi:10.1016/j.ajem.2014.02.038

Cited by 15 publications

(11 citation statements)

References 44 publications

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“…T wave changes in lead aVL might be considered nonsignificant by most physicians; however, a limited number of studies have shown the importance of T wave changes in recognition of right ventricular involvement in inferior wall MI [ 30 , 31 ] and sign of mid-LAD lesion [ 10 , 11 , 32 ]. Farhan et al found 14.1% of the ECGs they reviewed had TWI in lead aVL.…”

Section: Discussionmentioning

confidence: 99%

“…These changes have been studied to localize the site of a coronary lesion [ 7 ] and also are believed to be early and sensitive markers of myocardial infarction [ 8 ]. Reciprocal changes may be the only manifestation of acute myocardial ischemia and may be present in a single lead as ST depression in lead aVL [ 5 , 6 ] and TWI in lead aVL indicating a significant coronary artery lesion in left anterior descending (LAD) artery is another example [ 9 – 11 ]. The importance of these changes has not been emphasized and/or well recognized across all specialties.…”

Section: Introductionmentioning

confidence: 99%

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Isolated T Wave Inversion in Lead aVL: An ECG Survey and a Case Report

Hassen

Costea

Carrazco

et al. 2015

Emergency Medicine International

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Background. Computerized electrocardiogram (ECG) analysis has been of tremendous help for noncardiologists, but can we rely on it? The importance of ST depression and T wave inversions in lead aVL has not been emphasized and not well recognized across all specialties. Objective. This study's goal was to analyze if there is a discrepancy of interpretation by physicians from different specialties and a computer-generated ECG reading in regard to a TWI in lead aVL. Methods. In this multidisciplinary prospective study, a single ECG with isolated TWI in lead aVL that was interpreted by the computer as normal was given to all participants to interpret in writing. The readings by all physicians were compared by level of education and by specialty to one another and to the computer interpretation. Results. A total of 191 physicians participated in the study. Of the 191 physicians 48 (25.1%) identified and 143 (74.9%) did not identify the isolated TWI in lead aVL. Conclusion. Our study demonstrated that 74.9% did not recognize the abnormality. New and subtle ECG findings should be emphasized in their training so as not to miss significant findings that could cause morbidity and mortality.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Isolated T Wave Inversion in Lead aVL: An ECG Survey and a Case Report

Hassen

Costea

Carrazco

et al. 2015

Emergency Medicine International

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“…The reasons for the disparities in the diagnostic values among studies are likely multifactorial. First, although the definition of T wave inversion was unclear in previous studies, 5 6 12 we clearly defined T wave inversion according to the AHA definition; 9 therefore, our findings were less likely to be subject to information bias. Second, a previous study used a combination of T wave inversion in lead aVL and lead I to estimate the diagnostic values.…”

Section: Discussionmentioning

confidence: 90%

Does T wave inversion in lead aVL predict mid-segment left anterior descending lesions in acute coronary syndrome? A retrospective study

et al. 2016

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ObjectivesLimited data are available regarding the predictive value of electrocardiographic T wave inversion in lead aVL for mid-segment left anterior descending (MLAD) lesions among patients with acute coronary syndrome (ACS).SettingRetrospective single-centre study, using a prospectively-collected coronary angiography database from January 2012 to December 2013.ParticipantsWe included consecutive adult patients with ACS who underwent urgent percutaneous coronary intervention (PCI) within 24 h after arriving at the hospital. We excluded patients who did not undergo an ECG before PCI, patients with proximal MLAD occlusion and patients diagnosed with vasospastic angina.Primary and secondary outcome measuresThe primary outcome was MLAD lesion >50%. The other outcome of interest was MLAD lesion as a cause of ACS. First, we evaluated the diagnostic values of T wave inversion in lead aVL regardless of other T wave changes for each outcome. Second, we evaluated the diagnostic values of isolated T wave inversion in lead aVL.ResultsOverall, 219 patients were eligible for the analysis. T wave inversion in lead aVL regardless of other T wave changes had a sensitivity of 32.9%, specificity of 48.2%, positive predictive value of 27.6% and negative predictive value of 54.5% for predicting MLAD lesions. Isolated T wave inversion in lead aVL had a sensitivity of 9.8%, specificity of 86.9%, positive predictive value of 30.8% and negative predictive value of 61.7% for predicting MLAD lesions. These diagnostic values did not change materially when focusing on patients with MLAD lesion as the cause.ConclusionsWhile T wave inversion in lead aVL regardless of other T wave changes had low diagnostic values for predicting MLAD lesions, isolated T wave inversion in lead aVL had a high specificity. Our inferences underscore the importance of a cautious interpretation of T wave inversion in lead aVL among patients with ACS.

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“…ST depression in aVL (i.e. ST elevation in −aVL) in inferior STEMI has been shown to indicate severe disease and poor left ventricular ejection fraction [7], and to increase detection rate in inferior STEMI [5, 8, 9]. ST depression > 0.1 mV in aVL is indicative of right ventricular (RV) infarction [10].…”

Section: Main Textmentioning

confidence: 99%

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

Lindow

Birnbaum

Nikus

et al. 2019

BMC Cardiovasc Disord

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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.

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Lead aVL on electrocardiogram: emerging as important lead in early diagnosis of myocardial infarction?

Cited by 15 publications

References 44 publications

Isolated T Wave Inversion in Lead aVL: An ECG Survey and a Case Report

Isolated T Wave Inversion in Lead aVL: An ECG Survey and a Case Report

Does T wave inversion in lead aVL predict mid-segment left anterior descending lesions in acute coronary syndrome? A retrospective study

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

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