The Forgotten Lead: aVR in Left Main Disease

Sugammadex-induced atropine-resistant bradycardia: clinical, pathophysiologic, and electrocardiographic considerations

“…The lead aVR, until recent years, was regarded as the "neglected lead" [11]. However, reports have shown that ST-segment elevation of more than 1.0 mm in lead aVR associated with widespread ST-segment depression in inferolateral leads, as in the described patient, best identifies severe left main or 3-vessel disease with 80% sensitivity and 93% specificity [12]. Urgent coronary angiography is necessary to confirm this and the diagnosis is high-risk non-ST segment elevation acute coronary syndrome that requires urgent revascularization and medical treatment that includes anti-platelets, aspirin, and heparin [13].…”

Value of ST-Segment Elevation in Lead aVR for Predicting Severe Left Main or 3-Vessel Disease

“…4 ST-segment elevation of 1.0 mm in lead aVR best identified severe left main or 3-vessel disease with 80% sensitivity and 93% specificity. In the reported case, 1 ST-segment elevation in lead aVR was 1.5 mm on electrocardiogram during chest pain, and this electrocardiogram sign strongly suggests "severe" left main or 3-vessel disease that most likely would require urgent coronary artery bypass grafting. Therefore, we might consider withholding clopidogrel until immediate coronary angiography has been performed and then decide on the treatment strategy in this patient.…”

ST Elevation in aVR with Coexistent Multilead ST Depression

“…Discussion: Traditionally, lead aVR has not received attention when interpreting acutely ischemic changes on ECG, leading some to refer to it as "the forgotten lead." 1 Current guidelines acknowledge the significance of multilead ST depression with coexistent ST elevation in aVR, and this pattern has been identified as the strongest predictor of severe left main coronary artery and/or 3-vessel disease. [2][3] When this ECG pattern is recognized in patients with ischemic symptoms, the emergency physician should involve cardiology early.…”

“…When managing patients with suspected left main coronary artery and/or 3-vessel disease, it is important to withhold dual anti-platelet therapy as CABG is likely to be indicated, 1,3 and guidelines recommend discontinuing P2Y12 inhibitors like clopidogrel or ticagrelor at least 24 hours prior to urgent CABG. 2 Topics: ECG, electrocardiogram, STEMI, aVR elevation, The forgotten lead, left main disease, triple vessel disease.…”