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Category: Volume 06 Issue 10 October 2018
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Title: Electrocardiographic Significance of Lead aVR in Acute Myocardial Infarction

Authors: M.P.Holay, Milind Vyawahare, Pankaj Ferwani, Mukund Deshpande

 DOI:  https://dx.doi.org/10.18535/jmscr/v6i10.122

Abstract

Introduction: Role of lead aVR in localizing the level of obstruction in AMI has generated considerable interest in recent times. There is a plethora of articles studying the utility of lead aVR (ST segment elevation) in AMI with conflicting and contradictory results.

Methodology: This prospective study comprised of 100 subjects of Acute myocardial infarction (AMI) was aimed to determine utility of ST segment changes in lead aVR in terms of ST elevation in prediction of coronary artery involvement & correlating culprit coronary artery lesion on coronary angiogram (CAG). A12 lead ECG was done at admission and CPKMB level was done in all patients. CAG (coronary angiogram) was performed within 72 hrs. of hospitalisation in most of the cases except few in whom CAG was performed within 7 days. On ECG, lead aVR changes in the form of ST elevation were noted in terms of culprit coronary artery and were correlated and confirmed on CAG.

Results: Analysis of admission ECG revealed ST elevation in lead aVR in 28% of the cases. On CAG single & double vessel disease was observed in majority of the cases. LMCA occlusion was seen in 12% cases. (12 out of100) 10 (35.7%) cases out of 28 who showed ST segment elevation in aVR had significant LMCA occlusion on CAG, Diabetes, cardiogenic shock & Triple vessel disease were found as independent predictors  of elevated ST segment in lead aVR. It was statistically highly significant CPKMB levels were significantly high in cases with elevated ST in lead aVR (p = <0.0001).

Correlation between elevated ST in lead aVR & significant LMCA occlusion (>50%) on CAG was found statistically significant p = <0.0001, Odds ratio = 19.44 95% CI (3.55-190.30).with Sensitivity of 83.3%, Specificity 87.5%, positive predictive value 35.71%, negative predictive value as 97.22% & accuracy of 80%.

All 28 cases with elevated ST segment in lead aVR showed significant LAD occlusion on CAG. While 72 cases without  ST elevation in lead aVR revealed LAD occlusion in 54 (75%) cases. this difference was statistically significant p =0.003. but sensitivity, specificity positive & negative predictive value & diagnostic accuracy (34%,1%, 1% 28.8% & 28.18% respectively) is less than LMCA prediction  with ST segment elevation in lead aVR.

Conclusion: ST elevation in lead aVR has more predictability for significant occlusion of LMCA on CAG than LAD

Keywords: Acute Myocardial infarction (AMI), ECG, aVR lead, Coronary angiography (CAG) Left anterior descending artery (LAD), Left main coronary artery (LMCA).

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Corresponding Author

Dr Milind Vyawahare

Associate Professor in Medicine, Govt Medical College Nagpur-440003, India

Email: drmilind72gmail.com