How ST-segment elevation in aVR corelates with occlusion in the left main coronary artery

    Authors

    Abstract

    **Introduction:** Acute myocardial infarction (AMI) is one of the most common causes of death, especially in those who develop cardiogenic shock (CS). The ECG is a main tool in making a diagnosis of the localization of myocardial infarction (MI) and the possible location of the culprit lesion. ST-segment elevation (STE) in lead aVR is of great importance because it is a sign of either left main coronary artery (LM) occlusion or of proximal left anterior descending artery (LAD) or left circumflex artery (ACx) occlusion. STE in aVR > V1 STE suggests of the LM occlusion. The opposite ratio suggests of proximal LAD occlusion. Other ECG features of LM obstruction include diffuse ST-segment depression in precordial and inferior leads. Such patient demands an urgent myocardial reperfusion either via percutaneous coronary intervention (PCI) or, extremely rare, a coronary artery bypass grafting (CABG). CABG accounts STE in V1 and ST depression in other leads. Laboratory tests showed high troponin levels. Echocardiography showed hypokinesis of anteroseptolateral left ventricular wall with mild reduction in LV systolic function (EF 45%). Meanwhile, the patient developed CS, with high lactate levels. After patient stabilization by inotropes, an urgent coronarography was performed. It showed subocclusion of LM, as well as subocclusion of ostial LAD and left circumflex artery (ACx) which is additionally significantly stenosed in proximal segment, and proximal significant stenosis of right coronary artery (RCA). The patient was immediately transferred to cardiac surgery where triple CABG was created, LIMA with LAD and obtuse marginal branch (OM1) and RCA with vein saphena magna. Postoperatively, the patient was hemodynamically stable with normal LVEF. **Conclusion:** Previous studies showed that STE in aVR > STE in V1 suggest LMCA occlusion which we did not find in our patient. New recommendations for universal definition of myocardial infarction suggest that STE in aVR >1 mm is equivalent to myocardial infarction with STE.

    Keywords

    acute myocardial infarction, ST-segment elevation, aVR

    DOI

    https://doi.org/10.15836/ccar2018.304

    Literature

    1. Caceres M, Weiman DS. Optimal timing of coronary artery bypass grafting in acute myocardial infarction. Ann Thorac Surg. 2013 Jan;95(1):365–72. https://doi.org/10.1016/j.athoracsur.2012.07.018
    2. Joo JH, Liao JM, Bakaeen FG, Chu D. Surgical revascularization for acute coronary syndromes: a narrative review. Vessel Plus. 2018;2:2. https://doi.org/10.20517/2574-1209.2017.36
    Cardiologia Croatica
    Back to search

    How ST-segment elevation in aVR corelates with occlusion in the left main coronary artery

    Extended Abstract
    Issue11-12
    Published
    Pages304
    PDF via DOIhttps://doi.org/10.15836/ccar2018.304
    acute myocardial infarction
    ST-segment elevation
    aVR

    Authors

    Vera SlatinskiORCIDKlinička bolnica „Sveti Duh“, Zagreb, Hrvatska
    Ante Pašalić*ORCIDKlinička bolnica „Sveti Duh“, Zagreb, Hrvatska
    Tea FriščićORCIDKlinička bolnica „Sveti Duh“, Zagreb, Hrvatska
    Marko PerčićORCIDKlinička bolnica „Sveti Duh“, Zagreb, Hrvatska
    Zrinka PlaninićORCIDKlinička bolnica „Sveti Duh“, Zagreb, Hrvatska
    Jozica ŠikićORCIDKlinička bolnica „Sveti Duh“, Zagreb, Hrvatska
    Edvard GalićORCIDKlinička bolnica „Sveti Duh“, Zagreb, Hrvatska

    *Correspondence email: ante.pasalic@outlook.com

    Abstract

    **Introduction:** Acute myocardial infarction (AMI) is one of the most common causes of death, especially in those who develop cardiogenic shock (CS). The ECG is a main tool in making a diagnosis of the localization of myocardial infarction (MI) and the possible location of the culprit lesion. ST-segment elevation (STE) in lead aVR is of great importance because it is a sign of either left main coronary artery (LM) occlusion or of proximal left anterior descending artery (LAD) or left circumflex artery (ACx) occlusion. STE in aVR > V1 STE suggests of the LM occlusion. The opposite ratio suggests of proximal LAD occlusion. Other ECG features of LM obstruction include diffuse ST-segment depression in precordial and inferior leads. Such patient demands an urgent myocardial reperfusion either via percutaneous coronary intervention (PCI) or, extremely rare, a coronary artery bypass grafting (CABG). CABG accounts STE in V1 and ST depression in other leads. Laboratory tests showed high troponin levels. Echocardiography showed hypokinesis of anteroseptolateral left ventricular wall with mild reduction in LV systolic function (EF 45%). Meanwhile, the patient developed CS, with high lactate levels. After patient stabilization by inotropes, an urgent coronarography was performed. It showed subocclusion of LM, as well as subocclusion of ostial LAD and left circumflex artery (ACx) which is additionally significantly stenosed in proximal segment, and proximal significant stenosis of right coronary artery (RCA). The patient was immediately transferred to cardiac surgery where triple CABG was created, LIMA with LAD and obtuse marginal branch (OM1) and RCA with vein saphena magna. Postoperatively, the patient was hemodynamically stable with normal LVEF. **Conclusion:** Previous studies showed that STE in aVR > STE in V1 suggest LMCA occlusion which we did not find in our patient. New recommendations for universal definition of myocardial infarction suggest that STE in aVR >1 mm is equivalent to myocardial infarction with STE.

    Literature

    1. 1.
      Caceres M, Weiman DS. Optimal timing of coronary artery bypass grafting in acute myocardial infarction. Ann Thorac Surg. 2013 Jan;95(1):365–72.DOI
    2. 2.
      Joo JH, Liao JM, Bakaeen FG, Chu D. Surgical revascularization for acute coronary syndromes: a narrative review. Vessel Plus. 2018;2:2.DOI