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Does ST Elevation in aVR Require a STEMI Alert?

April 28, 2023

Written by Chris Thom

Spoon Feed
Previous guidelines suggested that isolated aVR elevation with multi-lead ST depression could be considered as a STEMI equivalent. However, current evidence suggests aVR elevation is not specific for an acute coronary event.

Why does this matter?
An acute coronary occlusion that results in STEMI morphology on EKG benefits from immediate re-vascularization. Entities termed ‘STEMI equivalents’ are understood to also represent acute coronary occlusion. Isolated aVR elevation has been previously discussed as a STEMI equivalent, but is it specific for acute coronary occlusion?

No helicopter ride this time…..  
This was a case report and review of isolated aVR elevation. It details a 50 year old with vomiting whose EKG revealed ST elevation of aVR and lead V1, with concomitant diffuse ST depression. Cardiology was consulted for emergent left heart catheterization. However, a repeat EKG after resuscitation showed normalization of the EKG. Further workup revealed gastric outlet obstruction secondary to a duodenal stricture.

The review notes that aVR elevation coupled with diffuse ST depression was previously accepted to be indicative of acute occlusion of the left main coronary or proximal left anterior descending artery. This pattern was classified as a STEMI equivalent in the 2013 ST-elevation myocardial infarction (STEMI) guidelines (1). However, subsequent literature has shown that this pattern is not specific for STEMI, with only one-fourth of individuals, in a study of 130 patients, having acute coronary syndrome (2). The recent 2022 ACC Expert Consensus Decision Pathway on this topic does not include aVR elevation as one of the accepted STEMI equivalents (3).

The review notes that there are 3 main categories wherein aVR ST elevation can occur: acute coronary occlusion, subendocardial ischemia from severe non-occlusive coronary artery disease or supply/demand mismatch, and repolarization abnormalities. In summary, always consider acute coronary occlusion with aVR ST elevation, but be aware that it is not entirely specific for an acute coronary occlusion.

Another Spoonful
See this discussion of aVR ST elevation with diffuse ST depressions on Dr. Smith’s ECG blog.

Does ST Elevation in Lead aVR Require an Emergent Trip to the Catheterization Laboratory? JAMA Intern Med. 2023 Mar 1;183(3):261-262. doi: 10.1001/jamainternmed.2022.5901.

Works Cited

  1. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation. 2013 Dec 24;128(25):e481].
  2. Knotts RJ, Wilson JM, Kim E, Huang HD, Birnbaum Y. Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease?J Electrocardiol. 2013;46(3):240-248.
  3. Writing Committee, Kontos MC, de Lemos JA, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022;80(20):1925-1960.

What are your thoughts?