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Journal of Electrocardiology 44 (2011) 27 – 30

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An unusual presentation of left anterior descending artery occlusion:

significance of lead aVR and T-wave direction
Enes E. Gul, MD, a,⁎ Kjell C. Nikus, MD b
a
Department of Cardiology, Meram School of Medicine, Selcuk University, Konya, Turkey
b
Department of Cardiology, Heart Center, Tampere University Hospital, Tampere, Finland
Received 28 June 2010

Abstract Acute occlusion of the left anterior descending coronary artery (LAD) is frequently encountered in
acute ST-elevation myocardial infarction. Early detection of the clinical entity by the presenting
electrocardiogram (ECG) should result in immediate aggressive clinical management. Although the
typical ECG pattern of LAD occlusion is ST elevation, also atypical presentations, like ST
depression, may occur. We describe a case with an unusual ECG pattern that suggested acute
anterior myocardial infarction due to LAD occlusion.
© 2011 Elsevier Inc. All rights reserved.

Introduction chest pain was 4 hours before admission to the emergency

department. The patient was on antihypertensive medication
An acute occlusion of the left anterior descending
and had no history of coronary artery disease. Twelve-lead
coronary artery (LAD) may result in a very extensive
ECG revealed sinus bradycardia 53 beats/min, and ST-
anterior myocardial infarction (MI). Alternatively, the infarct
segment depressions with positive T waves in the inferior
area may be restricted to the septal, apical-anterior, or
leads II, III, and aVF and in leads V2 to V6 (Fig. 1). The
midanterior regions of the left ventricle, depending on the
patient had no symptoms during the ECG recording. ST-
site of occlusion.1 Proximal LAD occlusion has been
segment elevation—more than 1 mm—was only seen in lead
documented as an independent predictor of poor prognosis
aVR. The ST segment could not be interpreted in lead V1
and recurrent MI.2 The electrocardiogram (ECG), which
because of technical artifacts. The blood pressure was 110/70
may predict an acute occlusion of the LAD, is very important
mm Hg, and on physical examination, the patient was in
for early management. There are different ECG criteria for
moderate respiratory distress. The plasma levels of both
predicting the site of occlusion within the LAD, that is,
troponin I and creatine kinase-MB were high on admission:
discrimination between proximal and distal LAD
11.0 ng/mL (reference value, b0.01 ng/mL) and 18,6 ng/mL
occlusion.3,4 However, the ECG markers have shown
(reference value, 0.54-4.19 ng/mL), respectively. Other
varying sensitivity and specificity and most studies have
laboratory tests were within normal limits. Bedside echo-
been retrospective. The often neglected lead aVR can be
cardiography revealed diffuse (global) hypokinesia of the
used to differentiate left main coronary artery (LMCA) from
left ventricle. Left ventricular ejection fraction was mildly
LAD occlusion.3 We present an unusual ECG pattern that
depressed (45%). Coronary angiography was immediately
revealed ST elevation in only lead aVR and extensive ST-
performed (∼4.5 hours from symptom onset) and showed
segment depression with positive T waves in the inferior and
subtotal occlusion of the proximal LAD with thrombolysis in
anterior leads due to proximal LAD occlusion.
MI 2 flow (Fig. 2A). The LAD extended to the left
ventricular apex, but only slightly beyond it. The inferior part
of the left ventricle was mainly irrigated by the right
Case report coronary artery (Fig. 2B). There was balanced dominant
coronary circulation. There were no significant (≥50 %)
A 50-year-old man presented at the emergency depart-
lesions in the other coronary arteries. Primary stenting was
ment complaining of chest pain and palpitations. Onset of
performed with a stent of 4.0 mm in diameter and 12 mm in
⁎ Corresponding author. Selcuk Universitesi, Meram Tip Fakultesi, length, and normal thrombolysis in MI grade 3 flow was
Kardiyoloji Sekreterligi, Meram, 42090 Konya, Turkiye. achieved. After the coronary stenting, the patient's ECG
E-mail address: elvin_salamov@yahoo.com revealed inverted T waves in leads V2 through V6 without
0022-0736/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.jelectrocard.2010.08.009
28 E.E. Gul, K.C. Nikus / Journal of Electrocardiology 44 (2011) 27–30
Fig. 1. The ECG showing diffuse ST-segment depressions with positive T waves in the inferior leads II, III, and aVF and in leads V2 to V6 besides ST-segment
elevation in lead aVR. ST elevation in lead aVR is more than 1 mm. The ST segment in lead V1 cannot be reliably analyzed because of technical artifacts.
any significant Q waves (Fig. 3). The patient was discharged
6 days after admission to the hospital.
Discussion
Our case highlights the importance of recognizing other
ECG patterns than ST elevation representing (subtotal)
coronary occlusion with a large area-at-risk. It also indicates
that some high-risk cases are missed when only patients
fulfilling reperfusion criteria are considered as candidates for
immediate coronary intervention. There are some ECG
criteria demonstrated in various studies for the diagnosis of
acute LAD occlusion in different clinical settings. Determi-
nation of the site of occlusion in the LAD; that is,
discrimination between proximal and distal LAD occlusion
is very important. Therefore, being able to predict the
location of LAD occlusion from the ECG at presentation,
enables advance therapeutic managements. Early determi-
nation of the site of occlusion may be crucial for deciding
about the mode of reperfusion therapy, especially in
geographical regions, where fibrinolytic therapy is a valid
alternative to primary percutaneous coronary intervention. In
the emergency room, we preliminary evaluated our patient's
ECG as suggestive of left main or 3-vessel disease because
of the widespread ST depressions in the precordial and in the
inferior leads with concomitant ST elevation in lead aVR.
Unfortunately, lead V1 could not be analyzed reliably due to
technical artifacts. Coronary angiography revealed the
culprit lesion in the proximal LAD. Because of proximal
LAD occlusion, the patient underwent coronary stenting. In
case of left main disease, we would have considered
coronary artery bypass grafting as an alternative to
percutaneous coronary intervention.
Different ECG criteria for proximal LAD occlusion are
not helpful in cases, where traditional criteria for acute ST-
elevation MI are not fulfilled. Eskola et al4 reported a
positive predictive value of 85% and negative predictive
value of 71% to predict a proximal LAD lesion on
coronary angiography using the following ECG criteria:
either ST elevation at least 0.5 mm in lead aVL or any ST
elevation in lead aVR in association with precordial ST-
segment elevation at least 2 mm in at least 2 contiguous
leads (including V2, V3, or V4). Fiol et al3 recommended
the use of a new algorithm for detecting the site of
occlusion. The have proposed the following criteria: (1)
ST-segment elevation in precordial leads V1, V2, and V4
through V6 indicates LAD occlusion; (2) for differentiation
of proximal versus distal occlusion, the sum of ST
depression in III and aVF leads at least 2.5 mm indicates
proximal LAD occlusion (criterion A); and (3) if the sum
of ST deviation in aVR + V1 − V6 ≥ 0, indicates proximal
LAD occlusion (criterion B). In our case, there are no ST-
segment elevations in leads V1, V2, or V4 to V6 to
indicate LAD occlusion. Instead, there are diffuse ST-
segment depressions in leads V2 through V6, and also in
the inferior leads.
The use of lead aVR to predict the site of occlusion is, to a
large part, neglected. ST-segment elevation in aVR has been
associated with left main or 3-vessel disease.5,6 Yamaji et al7
reported that ST elevation in lead aVR with less ST elevation
in lead V1 is a predictor of LMCA occlusion. In a review
article, Nikus and Eskola8 described ECG patterns in acute
LMCA occlusion and found widespread ST-segment
depression maximally in leads V4 to V6 with inverted T
waves and ST-segment elevation in lead aVR to be
indicative of this clinical entity. In a study by Aygul et al,9
ST elevation in lead aVR was a good indicator of proximal
LAD occlusion in ST-elevation MI patients.
In rather small studies, Sclarovsky et al10 and Nikus
et al11 compared non–ST-elevation acute coronary syn-
drome patients with ST depressions in the precordial leads
with respect to the direction of the T waves. They found that
in those with ST depressions and positive T waves, the LAD
was the culprit artery in most cases. The ST depressions in
these cases were thought to represent regional subendocar-
dial ischemia. The authors stated: “The dissociation between
ST-segment and T-wave orientation is an unusual ECG
finding, and represents a challenge for ECG interpretation in
 E.E. Gul, K.C. Nikus / Journal of Electrocardiology 44 (2011) 27–30
Fig. 2. A, Left anterior oblique caudal angiographic view shows a very tight
stenosis in the proximal LAD (arrow). LCx indicates left circumflex artery.
B, Right coronary artery with a large posterior descending (PD) but no
posterolateral (PL) branches (balanced dominance). No significant stenoses
are present.
Fig. 3. Discharge ECG of the patient showing inverted T waves in leads V2 through V6 and in leads I and aVL.
29
acute ischemic syndromes.” Later on, de Winter et al12
11
presented cases with the same ECG pattern, ST depression,
and positive T waves in proximal LAD disease. In all of the
8 cases presented in their letter to the editor, there was ST
elevation in lead aVR, but the ST-segment changes in the
inferior leads were not consistent.
In the present case, there was widespread ST depression,
maximally in lead V4, with positive T waves. Although we
do not know the exact pathophysiologic background for the
ECG pattern, we hypothesize that the patient had a large area
of regional ischemia, resulting in many leads with ST
depression. However, the ischemia was not severe enough to
induce elevation of the left ventricular end-diastolic pressure,
in which case, we would have expected widespread ST
depressions with inverted T waves (circumferential sub-
endocardial ischemia).
In the aforementioned study by Nikus et al,11 all patients
(n = 25) with ST depressions maximally in leads V4 to V5
with negative T waves had severe 3-vessel or left main
disease on coronary angiography. We cannot exclude a
spontaneously reperfused total LAD occlusion, where the
flow was partially restored at the time of the angiogram, but
we think that this is a less probable explanation. Although
the occlusive phase could have been missed, as the first ECG
was recorded some hours after symptom onset, the ECG
pattern in this case is not typical for the “post-ischemic”
phase of flow restitution. Inverted T waves with an
isoelectric or slightly elevated ST segment, not ST-segment
depression, is seen after a period of total coronary occlusion
with transmural ischemia.13
In conclusion, with this case, we want to point out that
ECG criteria and algorithms are very useful and important to
detect the site of coronary artery occlusion. Other ECG
patterns than ST elevation may represent high-risk cases.
T-wave direction my help in differentiating patients with
non–ST-elevation acute coronary syndrome, who have
single-vessel disease, from those with left main or left
main equivalent disease. Electrocardiogram criteria have
some limitations, as in our case, and therefore, we need more
studies in this field.
30 E.E. Gul, K.C. Nikus / Journal of Electrocardiology 44 (2011) 27–30
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