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ST-Segment Elevation in Lead aVR on the Presenting Electrocardiogram—Reply

ST-Segment Elevation in Lead aVR on the Presenting Electrocardiogram—Reply In reply We appreciate the thoughtful points raised by Dr Zema. We agree that left ventricular (LV) hypertrophy is another explanation for ST-segment elevation in lead aVR in addition to the diagnoses mentioned in our report.1 Indeed, an early case series studying the aV limb leads in the diagnosis of LV strain identified ST-segment changes in lead aVR as suggestive of LV strain in addition to the specific voltage criteria of S wave greater than 14 mm.2 Our reported patient did not have LV hypertrophy by either echocardiography or the electrocardiographic criteria used by Barrabés et al.3 In that study, the authors noted an increased frequency of LV hypertrophy in patients with ST-segment elevation in lead aVR and performed a subanalysis of the significance of ST-segment elevation in lead aVR only after excluding patients with LV hypertrophy. We also thank Dr Zema for sharing his expertise with stress testing in outpatients with suspected acute coronary syndrome. We agree that in patients who present acutely with high-risk electrocardiographic features concerning for left main coronary artery or multivessel disease (eg, diffuse ST-segment depressions and ST-segment elevation in lead aVR) in the setting of a suspected acute coronary syndrome, stress testing is in general contraindicated. As internists, the role of any stress testing in this scenario, including the use of modified and lower-intensity exercise protocols, should only be considered after consultation with a cardiologist to determine first whether an invasive strategy is optimal and safest. Back to top Article Information Correspondence: Dr Nakamura, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, GRB 740, Boston, MA 02114 (knakamura@partners.org). Financial Disclosure: None reported. References 1. Nakamura K, Berry NC, An PG, Dudzinski DM. Significance of ST-segment elevation in lead aVR. Arch Intern Med. 2012;172(5):389-39122412103PubMedGoogle ScholarCrossref 2. Schack JA, Rosenman RH, Katz LN. The aV limb leads in the diagnosis of ventricular strain. Am Heart J. 1950;40(5):696-70514783065PubMedGoogle ScholarCrossref 3. Barrabés JA, Figueras J, Moure C, Cortadellas J, Soler-Soler J. Prognostic value of lead aVR in patients with a first non-ST-segment elevation acute myocardial infarction. Circulation. 2003;108(7):814-81912885742PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

ST-Segment Elevation in Lead aVR on the Presenting Electrocardiogram—Reply

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References (10)

Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.2732
Publisher site
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Abstract

In reply We appreciate the thoughtful points raised by Dr Zema. We agree that left ventricular (LV) hypertrophy is another explanation for ST-segment elevation in lead aVR in addition to the diagnoses mentioned in our report.1 Indeed, an early case series studying the aV limb leads in the diagnosis of LV strain identified ST-segment changes in lead aVR as suggestive of LV strain in addition to the specific voltage criteria of S wave greater than 14 mm.2 Our reported patient did not have LV hypertrophy by either echocardiography or the electrocardiographic criteria used by Barrabés et al.3 In that study, the authors noted an increased frequency of LV hypertrophy in patients with ST-segment elevation in lead aVR and performed a subanalysis of the significance of ST-segment elevation in lead aVR only after excluding patients with LV hypertrophy. We also thank Dr Zema for sharing his expertise with stress testing in outpatients with suspected acute coronary syndrome. We agree that in patients who present acutely with high-risk electrocardiographic features concerning for left main coronary artery or multivessel disease (eg, diffuse ST-segment depressions and ST-segment elevation in lead aVR) in the setting of a suspected acute coronary syndrome, stress testing is in general contraindicated. As internists, the role of any stress testing in this scenario, including the use of modified and lower-intensity exercise protocols, should only be considered after consultation with a cardiologist to determine first whether an invasive strategy is optimal and safest. Back to top Article Information Correspondence: Dr Nakamura, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, GRB 740, Boston, MA 02114 (knakamura@partners.org). Financial Disclosure: None reported. References 1. Nakamura K, Berry NC, An PG, Dudzinski DM. Significance of ST-segment elevation in lead aVR. Arch Intern Med. 2012;172(5):389-39122412103PubMedGoogle ScholarCrossref 2. Schack JA, Rosenman RH, Katz LN. The aV limb leads in the diagnosis of ventricular strain. Am Heart J. 1950;40(5):696-70514783065PubMedGoogle ScholarCrossref 3. Barrabés JA, Figueras J, Moure C, Cortadellas J, Soler-Soler J. Prognostic value of lead aVR in patients with a first non-ST-segment elevation acute myocardial infarction. Circulation. 2003;108(7):814-81912885742PubMedGoogle ScholarCrossref

Journal

Archives of Internal Medicine – American Medical Association

Published: Aug 13, 2012

Keywords: electrocardiogram,st segment elevation

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