ST elevation aVR and diffuse ST depression in precordial

leads as a predictor Left Main Coronary Artery Stenosis

(LMCS) in Cardiogenic shock

Andri Octavallen, Hafifa Rahma, Ferry Limantara1,Dwiwardoyo, Bobi Prabowo2

1Emergency

Medicine Postgraduate Programme, Faculty of Medicine, Universitas Brawijaya, Indonesia

2Department of Emergency Medicine, Faculty of Medicine, Universitas Brawijaya, Indonesia

Introduction
Cardiogenic Shock complicated 7-10% of myocardial infaction with
mortality rate 70-80%.

Left main coronary artery supplied 75% of left ventricular myocardial

mass.
ST segmen elevation in aVR (STE-aVR) has been associated with left
main artery coronary stenosis(LMCS), proximal LAD or 3-vessel
disease.
The typical ECG for left main occulusion is a wide spread ST segmen depression
maximally in lead V4-V6 with inverted T wave and ST segmen elevation in lead
aVR

CASE REPORT

Case 1
A 58-years-old woman presented to the ER
complaining of chest pain since 4 hours ago
The patient also noted the onset of nausea, vomiting
and cold sweat
She denied cough,fevers,shortness of breath and
cardiac history
She has history of hypertension and DM
Vital signs were notable for pulse of 80 beats/min, BP
of unpalpable and respiratory rate of 24 breaths/min
Passed away 3 hours later

Results
An initial 12-leads EKG was obtained that
demonstrated :
There is ST elevasion in aVR
There is ST depression with negative T waves in leads
I, II, III, aVF and V4-V6
RBBB complete

Cardiac marker :
Troponin I : 0,3 g/L (N < 1,0)
CK-NAC : 313 U/L (N : 16,5-48,5)
CKMB : 55 U/L (N : 7-25)

EKG Case 1

EKG Case 1.cont

Right wall

Case 2
A 60-years-old man presented to the ER
complaining of chest pain since 8 hours ago
The patient also noted the onset of nausea,
vomiting and cold sweat
She denied cough,fevers,shortness of breath
cardiac history and hypertension
She has history of DM and heavy smoker
Vital signs were notable for pulse of 105
beats/min, BP of 60/palpable and respiratory rate
of 18 breaths/min

Results
An initial 12-leads EKG was obtained that
demonstrated :
There is ST elevasion in aVR
There is ST depression with negative T waves in leads
I, II, III, aVF and V1-V6
RBBB complete

Cardiac marker :
Troponin T : 2000 ng/ml (N < 0,05)
CK : 2996 U/L (N : 30-180)
CKMB : 55 U/L (N : 10-16)

ECG Case 2

Case 3
A 59-years-old man presented to the ER complaining of
chest pain since a half hours ago
The patient also noted cold sweat
She denied cough, nausea, vomiting, fevers, shortness
of breath
She has history of hypertension, DM and cardiac
history
Vital signs were notable for pulse of 103 beats/min, BP
of 95/73 and respiratory rate of 24 breaths/min
Passed away an hour later

Results
An initial 12-leads EKG was obtained that
demonstrated :
There is ST elevasion in aVR
There is ST depression with negative T waves in leads V1V6
There is ST depression I, II, III, aVF
RBBB complete

Cardiac marker :
Troponin I : 0,4 g/L (N < 1,0)
CK-NAC : 160 U/L (N : 16,5-48,5)
CKMB : 24 U/L (N : 7-25)

ECG Case 3

DISCUSSION

The Hallmark of acute injury

ST segment elevation
Accompanied by reciprocal ST
segment depression
ZIPES, D. P. & JALIFE, J. 2014. Electrocardiographic Imaging in Patients With Acute Coronary Syndrome. Cardiac
Electrophysiology: From Cell to Bedside. Sixth ed.

Lead aVR
Positive pole is oriented to the right
upper side of the heart
Usually gives a mirror image of the
leads oriented leftward

it is often ignored
BARRABS, J. A.,et al. 2003. Myocardial Infarction Prognostic Value of Lead aVR in Patients With a First Non-ST-Segment Elevation
Acute. Circulation American Heart Association.

ST-segment elevation in lead aVR

STE- aVR

+ Other repolarization changes

Associated with severe coronary artery lesions

in patients with unstable angina or STEMI
BARRABS, J. A.,et al. 2003. Myocardial Infarction Prognostic Value of Lead aVR in Patients With a First Non-ST-Segment
Elevation Acute. Circulation American Heart Association.

STE-aVR +
LMCA stenosis

ST depresion
in lead

Anterior
Lateral
Inferior

Extensive
CAD

Outcome

Poorer
outcome
Wall motion
abnormal

ROBERT J. KNOTTS, et al. 2013 Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to
left main coronary artery disease? Journal of Electrocardiology, 46, 240248.

aVR elevation
1. ST segment elevation in aVR and/or V1
2. ST-segment depression 0.1 mV in 8
limb leads
3. But are otherwise unremarkable

Ischemia due to
3-Vessel dis., Proximal LAD or LMCA obstruction
ROBERT J. KNOTTS, et al. 2013 Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia
due to left main coronary artery disease? Journal of Electrocardiology, 46, 240248.

Left Main Coronary Artery

LMCA occlusion/stenosis should be
suspected when RBBB and other features
of very Proximal LAD occlusion are
associated with signs of severe
posterobasal ischemia.
ZIPES, D. P. & JALIFE, J. 2014. Electrocardiographic Imaging in Patients With Acute Coronary
Syndrome. Cardiac Electrophysiology: From Cell to Bedside. Sixth ed.

Vektor

Resiprocal

Resiprocal

Posterobasal
ventricel

ZIPES, D. P. & JALIFE, J. 2014. Electrocardiographic Imaging in Patients With Acute Coronary Syndrome. Cardiac
Electrophysiology: From Cell to Bedside. Sixth ed

Vektorcont
Posterobasal
ventricel

ZIPES, D. P. & JALIFE, J. 2014. Electrocardiographic Imaging in Patients With Acute Coronary Syndrome. Cardiac
Electrophysiology: From Cell to Bedside. Sixth ed.

Conclusions
Lead aVR contains important shortterm prognostic information in
patients with NSTEMI

Conclusions..cont
Cardiogenic shock due to NSTEMI
with STE-aVR and diffuse ST
depression especially in precordial
leads must be assumed as LMCS
because its rapid clinical
deterioration