The Importance of ST Elevation in aVR
By Dr. Blake Collier
Brief Patient Presentation:
You sign up for a patient with chest pain and the EKG is concerning with ST elevation in aVR and diffuse ST depressions.
Clinical Question – PICO:
Which patients, if any, with ST elevation in aVR should warrant cath lab activation and/or cards consult to rule out Left Main Disease versus routine ACS rule out.
Classical electrocardiographic clues for left main coronary artery disease. Sen F1, Ozeke O1, Kirbas O2, Burak C1, Kafes H1, Tekin Tak B1, Ozdamar U1, Ocak K1, Topaloglu S1. – Level III
Value of ST-Segment Elevation in Lead aVR for Predicting Severe Left Main or 3-Vessel Disease. Masami Kosuge, MD, Kazuo Kimura, MD. –Level IV
Value of ST-Segment Elevation in Lead aVR for Predicting Severe Left Main or 3-Vessel Disease. Masami Kosuge, MD, Kazuo Kimura, MD. – Level IV.
REBEL EM and Amal MATU – Level V
Life in the Fast Lane – Level V
Does the literature in your search answer your question?
Yes, the literature review suggests that activating Cath lab for isolated ST elevation in AVR is not warranted. However, ST Elevation of more than 1mm in aVR in the setting of Acute Coronary syndrome is associated with left mainstem disease and 3 vessel disease, suggests urgent angiography is necessary, and is associated with an increase in mortality. In addition, a patient with truly ACUTE chest pain with ST elevation in AVR and diffuse ST depression should at the minimum warrant a conversation with cardiology, but if pain is un-remitting should go to the Cath Lab.
Does your search reveal a POEM?
Yes, Certain patient’s need much more aggressive care and intervention to get these patient’s early cath and possibly early surgical intervention.
How will you proceed the next time this problem is encountered?
In clinical practice, I would aggressively maximize medical therapy, and then have a discussion with cardiologist for admission and anti-coagulation vs. taking patient to cath lab.