AVR ST elevation
Background
- AVR elevation is commonly thought of as a sign of Left Main Coronary Artery (LMCA) occlusion. However, STE 0.5mm or greater in lead aVR to be present in 78% of patients with and 14% of patients without LMCA stenosis.[1]
- Use > 1mm and the clinical status of a patient if activating the cath lab based on aVR and concern for a STEMI
Clinical Features
Differential Diagnosis
ST Elevation
- Cardiac
- ST-segment elevation myocardial infarction (STEMI)
- Post-MI (ventricular aneurysm pattern)
- Previous MI with recurrent ischemia in same area
- Wellens' syndrome
- Coronary artery vasospasm (eg, Prinzmetal's angina)
- Coronary artery dissection
- Pericarditis
- Myocarditis
- Aortic dissection in to coronary
- Left ventricular aneurysm
- Left ventricular pseudoaneurysm
- Early repolarization
- Left bundle branch block
- Left ventricular hypertrophy (LVH)
- Myocardial tumor
- Myocardial trauma
- RV pacing (appears as Left bundle branch block)
- Brugada syndrome
- Takotsubo cardiomyopathy
- AVR ST elevation
- Other thoracic
- Metabolic
- Drugs of abuse (eg, cocaine, crack, meth)
- Hyperkalemia (only leads V1 and V2)
- Hypothermia ("Osborn J waves")
- Medications
- Tricyclic (TCA) toxicity
- Digoxin
Evaluation
Isolated elevation AVR is poorly specific for a LMCA. The following are other causes of aVR elevation:
- Nontraumatic thoracic aortic dissection
- Massive Pulmonary Embolism
- Massive GI bleed
- Left bundle branch block (LBBB)
- Left Ventricular Hypertrophy (LVH) with Strain Pattern
- Severe atrial tachydysrhythmias
Management
External Links
References
- Kosuge M et al. Predictors of Left Main or Three-Vessel Disease in Patients Who Have Acute Coronary Syndromes with Non-ST-Segment Elevation. Am J Cardiol 2005; 95: 1366 – 9. PMID: 15904646
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