In the context of Acute Coronary Syndromes (ACS), the presence of ST-segment elevation (STE) in lead aVR has emerged as a significant electrocardiographic marker indicating severe coronary artery disease, particularly left main coronary artery (LMCA) occlusion, proximal left anterior descending (LAD) artery occlusion, or triple vessel disease. This association is critical as it correlates with increased mortality rates among affected patients.
Studies have shown that STE in lead aVR is a strong predictor of LMCA disease and three-vessel coronary artery disease. For instance, Eren et al. demonstrated that STE in aVR, alongside elevated troponin levels, correlates highly with three-vessel occlusion and left main stenosis, leading to adverse clinical outcomes within 90 days (Eren et al., 2011). Similarly, Wang et al. conducted a meta-analysis that confirmed the prognostic implications of STE in lead aVR, emphasizing its role in identifying patients at risk of severe coronary artery disease (Wang et al., 2020). Moreover, Kossaify highlighted that STE in aVR, particularly when accompanied by ST-segment depression in other leads, is indicative of LMCA disease and can predict poor outcomes (Kossaify, 2013).
The electrocardiographic patterns associated with LMCA occlusion often include widespread ST depression in inferior leads and ST elevation in aVR, which can be critical for early diagnosis and intervention. Pradhan noted that specific ECG findings, such as ST elevation in lead aVR and V1-V4, are reflective of acute myocardial infarction due to LMCA occlusion or triple vessel disease, necessitating urgent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) (Pradhan, 2013). Furthermore, Kossaify emphasized that in cases of acute coronary syndromes, STE in aVR (≥1 mm) with diffuse ST depression is typically a sign of severe left main disease, which is associated with poor patient outcomes (Kossaify, 2013).
The clinical significance of STE in lead aVR extends beyond mere diagnosis; it serves as a vital tool for risk stratification in ACS patients. Studies have consistently shown that patients exhibiting this ECG pattern face higher in-hospital mortality rates and increased risks of reinfarction and heart failure (Santosa & Yuwono, 2021; , Elbehery et al., 2022). For example, a study by Elbehery et al. found that STE in aVR was a significant predictor for LMCA stenosis and three-vessel disease, reinforcing the need for careful monitoring and intervention in these patients (Elbehery et al., 2022).
In summary, the presence of ST-segment elevation in lead aVR during acute coronary syndromes is a crucial indicator of severe coronary artery disease, particularly LMCA occlusion and triple vessel disease. This finding is associated with significantly increased mortality and adverse clinical outcomes, underscoring the importance of prompt recognition and management in affected patients.
References:
- Elbehery, A., El-Menshawy, M., lrashid, M., & Allam, M. (2022). Coronary angiographic findings in acute coronary syndrome with and without st-segment elevation in lead avr patients. The Egyptian Journal of Hospital Medicine, 88(1), 3994-3998.
https://doi.org/10.21608/ejhm.2022.254074
- Eren, S., Aktaş, C., Korkmaz, İ., Karcıoğlu, Ö., Coşkun, A., & Guven, F. (2011). Prognostic value of avr lead and the well-known risk factors in acute st-segment elevated myocardial infarction. Hong Kong Journal of Emergency Medicine, 18(5), 287-293.
https://doi.org/10.1177/102490791101800504
- Kossaify, A. (2013). St segment elevation in avr: clinical significance in acute coronary syndrome. Clinical Medicine Insights Case Reports, 6.
https://doi.org/10.4137/ccrep.s11261
- Pradhan, D. (2013). Stenting of the left main coronary stenosis. Journal of Cardiovascular Diseases & Diagnosis, 01(03).
https://doi.org/10.4172/2329-9517.1000107
- Santosa, Y. and Yuwono, A. (2021). Successful percutaneous coronary intervention in a patient with avr st-segment elevation myocardial infarction due to spontaneous atherosclerotic coronary artery dissection. Cureus.
https://doi.org/10.7759/cureus.19545
- Wang, A., Singh, V., Duan, Y., Su, X., Su, H., Zhang, M., … & Cao, Y. (2020). Prognostic implications of st‐segment elevation in lead avr in patients with acute coronary syndrome: a meta‐analysis. Annals of Noninvasive Electrocardiology, 26(1).
https://doi.org/10.1111/anec.12811