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Challenges in Clinical Electrocardiography
June 2018

ST-Segment Elevation in Lead aVR: A Visual Reminder of Potential Catastrophe

Author Affiliations
  • 1Division of Geriatric Medicine, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
JAMA Intern Med. 2018;178(6):847-848. doi:10.1001/jamainternmed.2018.0928

A man in his 70s with a history of hyperlipidemia presented with sudden-onset chest pain that radiated to his left arm, with associated nausea and diaphoresis. Physical examination revealed a robust senior who appeared acutely ill, in obvious pain. Vital signs revealed a blood pressure of 119/62 mm Hg; pulse, 99 beats per minute and regular; and respirations, 20 breaths per minute. Oxygen saturation was 95% on ambient air. Cardiopulmonary examination disclosed a discrete 2/6 holosystolic murmur at the apex, with otherwise unremarkable findings. Chest x-ray was clear. His electrocardiogram (ECG) on presentation is shown in the Figure.

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1 Comment for this article
ST- segment elevation in aVR: a perspective
Rajeev Gupta, MBBS, MD, DM (Cardiology) | Mediclinic Al Jowhara Hospital, Al Ain, United Arab Emirates
I read with interest the article. I shall like to add the followings:
1. ST-segment elevation (STE) in aVR could be encountered in acute right ventricular overload like acute pulmonary thromboembolism also (1).

2. Greater STE in aVR than in V1 is indicates LMCA lesion, and the amount of STE is related to patients’ outcome. In proximal LAD block STE in V1 is greater than in aVR . In the study, STE in aVR is seen in 88% of patients with LMCA block, 43% patients with proximal LAD block (before first septal), and 8% of patients with RCA
block (large dominant RCA, supplying septum dominantly with posterolateral branches). (2)

3. In an interesting retrospective analysis, of STEMI activations patients with admission ECG showing STE in aVR, coexistant ST-segment depression in multiple leads (STD). Among 604 STEMI activations, 66 patients (11%) STE in aVR. Of those, 36% presented with cardiac arrest. Culprit coronary occlusion was identified only in 9%. 64% were found to have severe diffuse CAD with distal TIMI 3 flow and 36% had mild or no disease. STE in aVR was associated with 32% in-hospital mortality, compared to only 6.2%. The authors concluded STE in aVR was associated with acute thrombotic occlusion in 9% of patients and these patients had a five-fold higher in-hospital mortality compared with overall STEMI population. Majority had severe diffuse disease with extensive comorbidities and prior revascularizations. (3)
In a nutshell, STE in aVR could be encountered not only in patients with STEMI, it could be seen in patients with NSTEMI and severe diffuse CAD, and some patients with even mild or no CAD. Occasionally in could be encountered in patients with acute right ventricular strain. In patients with acute coronary syndromes, it portends a poorer outcome.

1. Van Mieghem C, Sabbe M, Knockaert D. The clinical value of the ECG in noncardiac conditions. Chest 2004;125:1561-76
2. Yamaji H, Iwasaki K, Kusachi S., et al. (2001) Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography: ST-segment elevation in lead aVR with less ST-segment elevation in leadV1. J Am Coll Cardiol 38:1348-1354
3. Harhash A, Reddy S, Huang-Tsang J, et al. (2017) Does ST-segment elevation in lead aVR corel;ate with left main occlusions? TCT-388 J Am Coll Cardiol 70: No. 18, suppl B, 2017.