Acute anterior wall myocardial infarction entailing ST-segment elevation
in lead V
3
R, V
1
or aVR: electrocardiographic and
angiographic correlations
Zhan Zhong-qun, MS,
⁎
Wang Wei, MS, Wang Chong-quan, MS, Dang Shu-yi, MS,
He Chao-rong, MS, Wang Jun-feng, MS
Department of Cardiology, Shiyan TaiHe Hospital, Yunyang Medical College, Shiyan, Hubei Province, China
Received 22 July 2007; accepted 5 December 2007
Abstract Background: The correlation between ST-segment elevation (ST↑) in lead V
3
R (ST↑
V3R
), lead V
1
(ST↑
V1
), and lead aVR (ST↑
aVR
) during anterior wall acute myocardial infarction (AMI) and the
culprit lesion site in the left anterior descending (LAD) coronary artery and the nature of the conal
branch of the right coronary artery has not been throughly described.
Methods: One hundred forty-two patients with first anterior wall AMI were included. The 15-lead
electrocardiogram with the standard 12 leads plus leads V
3
R through V
5
R showing the most
pronounced ST-segment deviation before initiation of reperfusion therapy was evaluated and
correlated with the exact LAD occlusion site in relation to the first septal perforator (S1) and the
nature of the conal branch of the right coronary artery as determined by coronary angiography.
Results: ST-segment elevation in lead aVR, ST↑
V1
of at least 2 mm, and ST↑
V3R
of at least 1 mm
were more prevalent among patients with occlusions proximal to S1 than patients with occlusions
distal to S1 (41.7% vs 4.9%, P b .01; 30.0% vs 7.3%, P b .01; and 91.7% vs 4.9%, P b .01,
respectively). Of the 60 patients with occlusions proximal to S1, 20 patients had a small conal branch
(18 patients with ST↑
aVR
and 15 patients with ST↑
V1
≥2 mm), and 24 patients had a large conal
branch (all patients with non-ST↑
aVR
and ST↑
V1
b2 mm; P b .01). The sensitivity of ST↑
V1
of more
than 1 mm, of at least 2 mm, ST↑
V3R
of at least 1.5 mm, and ST↑
aVR
for detecting a small conal
branch was 65.1%, 81.8%, 84.0%, and 90%, respectively; the specificity was 68.5%, 64%, 66.7%,
and 64.9%, respectively.
Conclusions: In patients with anterior wall AMI, ST↑
V3R
of at least 1 mm combined with ST↑ in leads
V
2
through V
4
were strongly predictive of LAD occlusion proximal to S1; furthermore, ST↑
aVR
and
ST↑
V1
of at least 2 mm were found to be useful in identifying LAD occlusion proximal to S1. ST↑
aVR
,
ST↑
V3R
of at least 1.5 mm, and ST↑
V1
of at least 2.0 mm were also associated with the presence of a
small conal branch not reaching the intraventricular septum during anterior wall AMI.
© 2008 Elsevier Inc. All rights reserved.
Keywords: Electrocardiography; Occlusion; Myocardial infarction
Introduction
The purpose of lead aVR is to obtain specific information
from the right upper side of the heart, such as the outflow
tract of the right ventricle (RV) and the basal part of the
septum. In practice, however, most electrocardiographers
consider lead aVR as giving reciprocal information from the
left lateral side, being already covered by the leads aVL, II,
V
5
, and V
6
. This is the reason why lead aVR has been largely
ignored.
1,2
In anterior wall acute myocardial infarction
(AMI), Engelen et al
3
found that, in proximal left anterior
descending coronary artery (LAD) obstruction with involve-
ment of the first septal perforator (S1), ST-segment elevation
(ST↑) in lead aVR (ST↑
aVR
) was present in 43% of the
patients. In distal occlusion of the LAD, not involving the
S1, no ST↑
aVR
but rather ST-segment depression in lead aVR
was observed. However, the reason for the rather low
sensitivity of this electrocardiographic (ECG) criterion has
Available online at www.sciencedirect.com
Journal of Electrocardiology 41 (2008) 329 – 334
www.jecgonline.com
⁎
Corresponding author. Department of Cardiology, Shiyan TaiHe
Hospital Affiliated to Yunyang Medical College, Shiyan 442000, Hubei
Province, China.
E-mail address: zzqun21@yahoo.com.cn
0022-0736/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jelectrocard.2007.12.004