|Year : 2019 | Volume
| Issue : 4 | Page : 383-390
Utility of aVR electrocardiogram lead for identifying the culprit lesion in patient with acute coronary syndrome
Virendra Patil, Kaustubh Pandere, Shoumita Damle, Aniket Avhad
Department of Medicine, Krishna Institute of Medical Sciences, Deemed to be University, Karad, Maharashtra, India
|Date of Submission||16-Jul-2019|
|Date of Decision||08-Aug-2019|
|Date of Acceptance||15-Oct-2019|
|Date of Web Publication||16-Jul-2020|
Dr. Virendra Patil
Department Medicine, Krishna Institute of Medical Sciences, Deemed to be University, Karad - 415 110, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The lead aVR is neglected electrocardiography (ECG) lead while interpreting various cardiac diseases including coronary artery disease (CAD). The aVR lead is a potentially useful tool in ECG in diagnosing and managing patients with CAD. Aim and Objectives: The aim is to study the usefulness of ECG in localizing the culprit vessel by coronary angiogram (CAG) in patients with the acute coronary syndrome (ACS) and to find the relation of ECG findings, with regional wall motion abnormality (RWMA) and CAG profile. \Materials and Methods: This was a cross-sectional observational study done on patients admitted with the diagnosis of ACS. A total of 54 patients were included in this study satisfying the inclusion criteria presented with ACS. Results: A total of 54 patients (males: 55.7% and females: 46.3%) were enrolled fulfilling inclusion criteria of the study (male: 59.72 [±10.59], female: 55.24 [±11.93]). A total 59.36% of patients had resulting RWMA. About 33.33% of patients had single-vessel disease, 24.07% had double-vessel disease , and 18.52% had triple-vessel disease (TVD) with P = 0.081. A total 79.62% of patients ECG could able to diagnose CAD. About 100% of patients with proximal left anterior descending (LAD) lesion 85.71% with LMCA, 40% with TVD had ST elevation in aVR lead. About 66.67% of patients with the right coronary artery (RCA) and 50% with left circumflex infarction (LCx) lesion had ST depression in aVR lead. About 59.36% had RWMA on echocardiogram. Conclusions: The presence of ST elevation in aVR indicates a culprit lesion in the proximal segment of LAD or LMCA. The absence ST elevation in aVR excludes the left main coronary artery as the underlying cause in the context of anterior wall ST-elevation myocardial infarction (STEMI). ST elevation in aVR is valuable for distinguishing proximal from distal lesions in the LAD in anterior wall STEMI. ST-segment depression in lead aVR is valuable for differentiating RCA from those with LCx in the inferior STEMI. Echocardiography findings aid triage for the management of the patient with ACS.
Keywords: Acute coronary syndrome, coronary angiogram, lead aVR, left anterior descending artery, left main coronary artery, regional wall motion abnormality, ST elevation myocardial infarction
|How to cite this article:|
Patil V, Pandere K, Damle S, Avhad A. Utility of aVR electrocardiogram lead for identifying the culprit lesion in patient with acute coronary syndrome. J Datta Meghe Inst Med Sci Univ 2019;14:383-90
|How to cite this URL:|
Patil V, Pandere K, Damle S, Avhad A. Utility of aVR electrocardiogram lead for identifying the culprit lesion in patient with acute coronary syndrome. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2021 Jun 15];14:383-90. Available from: http://www.journaldmims.com/text.asp?2019/14/4/383/289782
| Introduction|| |
Acute myocardial infarction (AMI) is a disease associated with significant mortality, morbidity, and cost to the society worldwide. AMI is a potential health problem due to life-threatening complications. Although coronary angiogram (CAG) is the gold standard to localize the site of coronary obstruction, electrocardiography (ECG) is an important tool in determining therapeutic strategy in acute coronary syndrome (ACS) in the setting of AMI. Among the 12 leads studied in ECG, lead aVR can be considered as the most forgotten part of it since no attention is paid to it as the mirror image of other leads., The diagnosis of infarct-related artery (IRA) is very important with regard to the prediction of potential complications, risk stratification, and subsequent therapeutic strategy in the setting of acute inferior myocardial infarction. Therefore, the present study was designed with the aim of evaluating the prevalence of ST-segment changes in lead aVR and its utility for identifying the culprit lesion on CAG.
| Materials and Methods|| |
Aim and objectives
- To determine the relation of ST-segment changes in electrocardiogram with the site of occlusion in culprit coronary vessel and IRA in patients with ACS
- To evaluate the role of aVR lead in identifying the culprit lesion
- To find the relation of ECG findings, regional wall motion abnormality (RWMA) segment wise by echocardiogram.
This was a cross-sectional observational study done on patients with the diagnosis of ACS. Study setting: This study was conducted in KIMS Hospital, Medicine and cardiology department over the period of 1 year (April 2018 to March 2019). The institutional ethical committee approval was taken. The informed and written consent was obtained from patients before enrolment for the study. Inclusion criteria were patients with the diagnosis of an ACS undergoing CAG. The patient with valvular heart disease, implanted pacemaker or prosthesis in the heart, cardiomyopathy and hepatic and renal dysfunction were excluded from this study. The patients with the diagnosis of ischemic heart disease and who had the previous history of percutaneous transcoronary angioplasty or coronary artery bypass grafting done were also excluded from the study. A total of 54 patients were included in this study satisfying the inclusion criteria. All enrolled patients underwent hemoglobin, serum creatinine, fasting lipid profile, blood sugar level, resting 12-lead ECG, CK-MB, Trop-I, two-dimensional (2D) transthoracic echocardiogram (RWMA segment wise, i.e., 1–17), and CAG.
- Unstable angina (UA), non-ST elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI) were labeled as per ACC/AHA guidelines
- Visual diameter stenosis of >70% on the basis of anatomy (left anterior descending [LAD], left circumflex infarction [LCx], right coronary artery [RCA] lesions), 50% for left main coronary artery (LMCA) equivalent lesions which was taken as significant anatomical stenosis. Coronary artery disease (CAD) was categorized as single-vessel disease (SVD), double-vessel disease (DVD), or triple-vessel disease (TVD) according to the number of major branches with significant involvement according to ACC/AHA guidelines
- Standardized myocardial segmentation and nomenclature (echocardiographic seventeen segment model) was done according to the American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging (2002) [Table 1].
|Table 1: Echocardiographic seventeen segment model for regional wall motion abnormality|
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Data collected were entered into Microsoft Excel. Data were analyzed for mean, percentage, standard deviation, and Chi-square test for quantitative data by using Microsoft Excel spreadsheet. Appropriate statistical tests were applied using SPSS software version 21 (trial version) (Chicago, Illinois, USA) for analysis and value of P < 0.05 was considered statistically significant.
| Results|| |
A total of 54 patients were enrolled fulfilling the inclusion criteria of the study. Of them, 29 (55.7%) were males and 25 (46.3%) were female (P = 0.059) with mean for age in male gender was 59.72 (±10.59) and female gender was 55.24 (±11.93) [Table 2].
A total of 35.19% had UA, 27.78% had NSTEMI, 9.26% had anterior wall STEMI, 25.93% had inferior wall STEMI (IW-STEMI) and 1.85% had anterolateral wall STEMI. Total patients were 40. Sixty-four percent had no obvious resting RWMA and 59.36% had RWMA (P < 0.05). The ECG changes were well correlated with RWMA (P < 0.002) [Table 3].
|Table 3: Echocardiogram findings (regional wall motion abnormality) in patient with electrocardiography changes|
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Of total 54 patients, 24.07 had mild CAD, 33.33% had SVD, 24.07% had DVD, and 18.52% had TVD (P = 0.081). In the present cohort of patients with the diagnosis of ACS, ECG could able to diagnose CAD abnormality in 43 (79.62%) patients [Table 4].
A total of 24.07% of patients had mild CAD in CAG. A total 5.56% patients had proximal LAD lesion of them 100% had ST elevation in aVR, I, aVL, and V5-V6. Total 12.96% of patients had LMCA lesion of them 85.71% had ST elevation in aVR, V1 to V6 with ST depression in I, aVL [Figure 1] and [Figure 2]. About 18.52% of patients had TVD of them 40% had ST elevation in aVR, I, aVL. About 7.41% of patients had LAD and LCx lesion, whereas 16.67% patients had LAD with RCA involvement. 1.11% of patients had RCA lesion of them 66.67% had ST depression in aVR, with ST elevation in II, II, aVF. Total 3.70% patients had LCx lesion of them 50% had ST depression in aVR, with ST elevation in II, III, and aVF leads. Total 22 (40.74%) had ST segment changes in aVR lead of them 9 (40.90%) were with proximal LAD and LMCA with ST elevation in aVR. Total 5 (22.72%) patients had ST depression in aVR lead with RCA or LCx lesion [Table 5] and [Table 6].
|Figure 1: Electrocardiography with aVR ST elevation myocardial infarction in patient with left main coronary artery lesion|
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|Figure 2: Electrocardiography of post percutaneous transcoronary angioplasty to the left main coronary artery lesion|
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|Table 5: Relation of changes in electrocardiography leadsg with infarct.related artery involved|
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|Table 6: Relation of electrocardiography and echocardiogram findings with culprit vessel involved on coronary angiogram|
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In multivariate analysis, ST elevation in aVR was significantly associated with Proximal LAD and LMCA and ST depression were associated with RCA than LCx (P < 0.002) [Graph 1].
Ethical clearance was obtained from the Institutional Ethical Committee of Krishna Institute of Medical Sciences, Deemed to be University, Karad, Maharashtra, India on 8th May 2019. With ethical clearance no KIMS(DU)/EC/2019-20/22.
| Discussion|| |
The identification of the culprit vessel and the localization of the ST elevation myocardial infarction (STEMI) are provided by coronary angiography (CAG) and is the gold standard. Over the last decade, literature is focused on the reassessment of the ECG as a reliable technique to obtain this useful information. ECG is an vital bedside tool in determining therapeutic strategy in ACS. In LMCA occlusion, more ST-segment elevation is present in lead aVR compared to lead V1. The ST-segment elevation in lead V1 is less in the LMCA lesion than in the LAD. The finding of ST-segment elevation in lead aVR ≥ V1 distinguished the LMCA lesion from the LAD lesion. Acute anterior wall infarction due to proximal LAD occlusion associated with aVR elevation. ST-segment depression in lead aVR in inferior wall ST-segment elevation myocardial infarction predicts left LCx. Lead aVR can give invaluable clues regarding the level and extent of coronary occlusion, and help the angiographer plan his or her interventional approach. The site of occlusion of LAD coronary artery is important in acute anterior myocardial infarction because proximal occlusion is associated with less favorable outcome and prognosis., Diagnostic ST elevation in the absence of LV hypertrophy or left bundle branch block is defined as new ST elevation at the J point in at least two contiguous leads of ≥2 mm (0.2 mV) in men or ≥1.5 mm (0.15 mV) in women in leads V2–V3 and/or of ≥1 mm (0.1 mV) in other contiguous chest leads or the limb leads. ST depression in ≥2 precordial leads (V1–V4) may indicate transmural posterior injury and multi-lead ST depression with coexistent ST elevation in lead aVR has been described in patients with left main or proximal LAD occlusion. Transthoracic 2D echocardiography may show regional wall motion abnormalities (RWMA) and facilitate triage in patients with difficult ECG findings. If doubt persists, immediate referral for invasive angiography may be necessary to guide therapy and cardiac troponin is the preferred biomarker for diagnosis of MI. ST elevation in aVR strongly predicted proximal LAD occlusion and aVR ST elevation greater than the V1 predicts acute LMCA occlusion. ST elevation in lead aVR more than in V1 prompts an early angiography and early intervention, which will result in superior outcomes. ST change in lead aVR can give valuable clues regarding the level and extent of coronary occlusion, and help the angiographer plan approach.,, The 12-lead ECG including the ST-segment shift in lead a VR is a crucial tool in the diagnosis and risk stratification and useful information on the coronary angiographic anatomy of ACS. In the present cohort of patients with the diagnosis of ACS, ECG could able to diagnose CAD abnormality in 43 (79.62%) patients. Proximal LAD lesion 100% and LMCA 85.71% associated with ST elevation in lead aVR and 66.67% RCA lesion associated with ST depression (P < 0.002). Similarly, Slavich et al. (n = 343) quoted the sensitivity LAD, RCA, LCX and the diagonal branch was 98.8%, 93.7%, and 31.7%, respectively, and the proximal/distal location was correctly identified in 62.4% of cases. Sanaani et al., in their retrospective study of 131 patients, 29 had STEMI and 102 had NSTEMI. Patients with anterior STEMI had LAD obstructive CAD. Patients with inferior STEMI were highly likely to have RCA or LCx lesions. In the present cohort, one-third had an LAD lesion and one third had an RCA lesion. Nikus and Eskola reported that the typical ECG finding in cases with preserved flow through the left main is widespread ST-segment depression maximally in leads V4-V6 with inverted T waves and ST-segment elevation in lead aVR. LMCA occlusion associated with lead aVR ST elevation, widespread ST-segment depressions, especially in leadsV4-V6 with inverted T waves or ST elevation in I and aVL. Similarly, in the present study, 85.71% LMCA lesion associated with ST elevation in lead aVR with ST depression in anterior and lateral leads. Khanal et al. studied 56 patients with acute inferior wall STEMI. The culprit artery was RCA in 71.4% patients and LCX in 23.2% of patients RCA-related infarction with ST-elevation lead III > lead II and LCX-related infarction with ST-elevation lead II > lead III. ST depression in aVR was associated with diagnosing LCX as the IRA. Similarly, in the present study, 11.11% had RCA and 3.70% had LCx lesion with ST depression was observed in 66.67% with RCA and 50% with LCx lesion. Hengrussamee et al. reported aVRSTE (>0.1 mV) was detected in the LMCA group 80%, RCA group 27%and LAD 25%. The findings of aVRSTE distinguished the LMCA group from the non LMCA group (LAD, RCA and LCX). They concluded that, in patients with ACS, lead AVR ST-segment elevation is associated with the culprit left main coronary lesion. In the present study, 100% proximal LAD and 85.71% LMCA lesion associated with ST elevation in lead aVR and 66.67% with RCA and 50% LCx had ST depression in aVR lead. Similarly, Chakraborty et al. studied 100 patients with STEMI and reported that the ECG can anticipate the culprit artery in STEMI patients to localize the infarct-related artery in anterior wall myocardial infarction (AWMI) and inferior wall myocardial infarction (IWMI). Mohanty and Saran quoted that the ST-segment depression was seen in lead aVL and ST elevation in lead III in RCA occlusions. In LCx occlusions, significantly, more ST depression was seen in leads V1-3 and ST elevation in lead II. The prominent ST depression was seen in lead aVL and ST elevation in V1in proximal RCA occlusions; these findings are comparable with the present study. Li et al. studied 240 clinical cases with AIMIundergoing PCI. The RCA was shown to be the IRA in 177 patients, while LCx was responsible for AIMI in 63 cases. ST-segment elevation in lead II, III and AVF found in all patients. The changes of STD I, STE III < STE II, STD aVL < STD I could discriminate between LCX and RCA in AIMI patients. These findings are comparable with the present study in which 11.11% of patients had RCA lesion of them 66.67% had ST depression in aVR, with ST elevation in II, II, aVF. Total 3.70% patients had LCx lesion of them 1 (50%) had ST depression in aVR, with ST elevation in II, III and aVF lead with reciprocal changes in I, aVL. Vasudevan et al. studied 50 patients with acute anterior myocardial infarction. ST-segment elevation in lead aVR, ST-segment depression in lead V5 and ST-segment elevation in V1 > 2.5 mm strongly predicted LAD occlusion proximal to first septal, whereas abnormal Q wave in V4-6 was associated with occlusion distal to first septal. Abnormal Q wave in lead aVL was associated with occlusion proximal to first diagonal, whereas ST depression in lead aVL was suggestive of occlusion distal to the first diagonal branch. Mahmoud et al. studied 50 patients with IWSTEMI with LCx was the culprit artery in 47% and RCA was the culprit artery in 53%. The LCx was the culprit artery in 4 (12%) and RCA was the culprit artery in 88% of patients with aVR depression had significantly larger infarctions. In the present study, 100% proximal LAD lesion, 85.71% LMCA lesion and 40% TVD lesion had ST elevation in aVR and 66.67% RCA lesion 50% LCx lesion had depression in aVR. Similarly, Mahmoud et al. in their (n = 288) study quoted that, the prevalence of ST-segment changes in lead aVR was estimated to be 58.3% with eight times increase in in-hospital mortality risk. Huang et al. in their study of 194 patients with IWSTEMI, found that the most powerful ECG criteria were the ratio of ST elevation in lead III to that in lead II, the ratio of ST depression in lead I to that in lead aVL, these findings are comparable with the present study. Salunke and Khyalappa in their prospective observational study (n = 50), 34 had the anterior wall, and 16 had inferior wall myocardial infarction. ST↑>1 mm in V4R, ST ↓ V3/ST ↑ LIII < 0.5 were equally sensitive for diagnosing proximal RCA occlusion. For left circumflex occlusion, ST elevation in lead III > lead II was the most sensitive and ratio of ST ↓ V3/ST ↑ LIII > 1.2 was the most specific criterion. In anterior wall STEMI, Q wave in aVL had maximum sensitivity for identifying occlusion proximal to D1 and Q wave in leads V4, V6 for occlusion distal to S1. These findings are comparable with the present study. Cheng et al. (TVD) quoted an ECG algorithm for predicting TVD from SVD in patients with STEMI for appropriate reperfusion strategy. Similarly, in the present study, 18.52% of patients had TVD of them 40% had ST elevation in aVR, I, aVL [Table 7].
|Table 7: Comparison of various studies[,,,,,,,,,,,,,,|
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The ECG is the most accessible and widely used diagnostic tool for patients with symptoms suggestive of acute myocardial ischemia. The prognosis of the high-risk patients with n ACS can be improved by correct diagnosis and early invasive therapy for a better outcome. 
| Conclusions|| |
In the present cohort about one-third of the population presenting with ACS had SVD followed by DVD and TVD with more than one-third of the population had ST-segment changes in aVR lead. The present study highlighted the importance of aVR lead in LMCA, proximal LAD and differentiation of RCA form LCx for better planning of early invasive therapy in the setting of ACS. The anterior ischemic ECG changes (NSTEMI) were predictive of LAD lesion. Transthoracic 2D echocardiography showed RWMA in about two-third of the population and aid triage in patients with difficult ECG findings also rule out other cardiac diseases mimicking CAD and find out complications consequences of ACS at large. Our results support that the careful interpretation of the ECG, appears useful in the detection of the culprit vessel and the coronary occlusion site in STEMI patients, with its implications for early risk stratification, reperfusion and selection of appropriate therapeutic strategy. Cardiologists should pay more attention to the tracing of lead aVR when interpreting the 12-lead ECG in clinical practice.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]