Author Affiliations: Departments of Medicine (Dr Nakamura) and Cardiology (Dr Dudzinski), Massachusetts General Hospital, Harvard Medical School, Boston.
We appreciate the thoughtful points raised by Dr Zema. We agree that left ventricular (LV) hypertrophy is another explanation for ST-segment elevation in lead aVR in addition to the diagnoses mentioned in our report.1 Indeed, an early case series studying the aV limb leads in the diagnosis of LV strain identified ST-segment changes in lead aVR as suggestive of LV strain in addition to the specific voltage criteria of S wave greater than 14 mm.2 Our reported patient did not have LV hypertrophy by either echocardiography or the electrocardiographic criteria used by Barrabés et al.3 In that study, the authors noted an increased frequency of LV hypertrophy in patients with ST-segment elevation in lead aVR and performed a subanalysis of the significance of ST-segment elevation in lead aVR only after excluding patients with LV hypertrophy.
Nakamura K, Dudzinski DM. ST-Segment Elevation in Lead aVR on the Presenting Electrocardiogram—Reply. Arch Intern Med. 2012;172(15):1190-1191. doi:10.1001/archinternmed.2012.2732