Lead aVR Should Not Be Neglected

Abstract

To the Editor We read with great interest the case report by Dr Vallelonga and colleauges 1 regarding an extremely subtle alteration on the electrocardiogram (ECG) tracing of a patient who had experienced occlusive myocardial infarction. The case was excellently presented; however, we would like to emphasize the critical role of lead aVR.Subtle ST-segment elevation (STE) in leads V 1 through V 3 and slight ST-segment depression in inferolateral leads were demonstrated in these ECG findings on admission (Figure , A 1 ). However, STE in lead aVR (STE-aVR) was not properly described. A sign of proximal left anterior descending (LAD), left main coronary artery (LMCA) stenosis, or severe triple-vessel disease, STE-aVR is used to assess the need for coronary artery bypass graft surgery. It has a high specificity for the left main disease (0.86; P < .001) 2 and is closely associated with inhospital death rates, recurrent ischemic events, and heart failure, and its absence can nearly exclude a substantial LMCA lesion. The presence of STE in lead aVR that is more prominent than in lead V 1 may distinguish LMCA obstruction from LAD and right coronary artery occlusion. 3 However, the subtle magnitude of STE in both leads aVR and V 1 (Figure, A 1 ) makes the differential diagnosis of LMCA and proximal LAD difficult.If LMCA or severe triple-vessel disease cannot be ruled out, the clinician must take additional risks into consideration when making decisions on subsequent treatment, eg, the timing of possible emergency procedures (regular daytime hours are preferred). A review by a multidisciplinary heart team may also be advisable. 4 This case report was very informative. We are inspired and are mentioning STE-aVR as complementary information. Double-voltage ECG recordings also may be helpful for interpretation of this subtle ECG change.