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

Abstract

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.

Association of St Elevation in Lead Avr With Left Main Stem and Triple Vessel Diseases in Patients With Non-St Elevation Myocardial Infarction

“…3,4 The lead aVR is often ignored in clinical practice. 5 However, different studies have shown that ST elevation in lead aVR can predict adverse events in NSTEMI patients more accurately. 6,7 Furthermore, ST elevation in aVR is a simple and an easy indicator of left main stem (LMS) or triple vessel disease (3VCAD) and can guide for the triage of these highrisk patients.…”

Completing the Cabrera Circle: deriving adaptable leads from ECG limb leads by combining constraints with a correction factor

“…Except for some rare current occurrences (Dower et al 1990, Sgarbossa et al 2004, Case and Moss 2010, Lam et al 2015, Lindow et al 2019, neither the Cabrera sequence nor its extension to a circle seem to be in widespread use. We hope, that the proposed Cabrera Circle together with the open-source software provided given will help to further extend the use of this methodology.…”

An Artificial Heart System for Testing and Evaluation of Cardiac Pacemakers

“…Although the programmers allow to test the PCM, ICD and CRT instruments functionality, they are not adapted to more complex simulations, such as pacemakers generated pulses measurement and visualization, its response to various states, evaluation of time intervals and synchronization of the intrinsic cardiac activity and finally the pacemaker activity in real-time [28,29]. These options would be useful for demonstration of a pacemaker function, mainly for academic and educational purposes -simulation of pathological states of the electrical conduction system of the heart-and scientific purposes -improving the design of new adaptive algorithms for pacemakers -.…”