AVR ST elevation

Background

• AVR elevation is commonly thought of as a sign of Left Main Coronary Artery (LMCA) occlusion. However, STE 0.5mm or greater in lead aVR to be present in 78% of patients with and 14% of patients without LMCA stenosis.
• Use > 1mm and the clinical status of a patient if activating the cath lab based on aVR and concern for a STEMI

Differential Diagnosis

ST Elevation

• Cardiac
  • ST-segment elevation myocardial infarction (STEMI)
  • Post-MI (ventricular aneurysm pattern)
  • Previous MI with recurrent ischemia in same area
  • Wellens' syndrome
  • Coronary artery vasospasm (eg, Prinzmetal's angina)
  • Coronary artery dissection
  • Pericarditis
  • Myocarditis
  • Aortic dissection in to coronary
  • Left ventricular aneurysm
  • Left ventricular pseudoaneurysm
  • Early repolarization
  • Left bundle branch block
  • Left ventricular hypertrophy (LVH)
  • Myocardial tumor
  • Myocardial trauma
  • RV pacing (appears as Left bundle branch block)
  • Brugada syndrome
  • Takotsubo cardiomyopathy
  • AVR ST elevation
• Other thoracic
  • Pneumomediastinum
  • Pneumothorax
  • Pulmonary embolism
• Metabolic
  • Drugs of abuse (eg, cocaine, crack, meth)
    • Cocaine chest pain
  • Hyperkalemia (only leads V1 and V2)
  • Hypothermia ("Osborn J waves")
• Medications
  • Tricyclic (TCA) toxicity
  • Digoxin

Evaluation

Isolated elevation AVR is poorly specific for a LMCA. The following are other causes of aVR elevation:

• Nontraumatic thoracic aortic dissection
• Massive Pulmonary Embolism
• Massive GI bleed
• Left bundle branch block (LBBB)
• Left Ventricular Hypertrophy (LVH) with Strain Pattern
• Severe atrial tachydysrhythmias
• A chronic elevation without clinical significance

External Links

• Amal Mattu aVR podcast