Editor's Correspondence |

ST-Segment Elevation in Lead aVR on the Presenting Electrocardiogram

Michael J. Zema, MD
Arch Intern Med. 2012;172(15):1190-1191. doi:10.1001/archinternmed.2012.2079.
Text Size: A A A
Published online


Much attention has recently been given to the use of ST-segment elevation (STE) in electrocardiographic lead aVR in the setting of acute coronary syndromes as indicative of left main and/or proximal left anterior descending coronary artery disease.1 It must be remembered, however, that STE in lead aVR is not specific for these coronary findings. While Nakamura et al1 discuss a differential diagnosis in their “Comment” section, they fail to mention one of the most common causes of STE in lead aVR, which is left ventricular (LV) hypertrophy. Left ventricular hypertrophy, usually but not always, shifts the QRS axis leftward in the frontal plane, with secondary ST-T abnormalities directed rightward. While the classic “LV strain pattern” is most often noted in limb leads 1 and aVL, because of an ST-segment vector directed between +60° and +240°, there are cases of LV hypertrophy with an ST-segment vector of approximately +270° (as in this case) wherein the ST-segment vector continues to lie on the positive side of the perpendicular to the aVR lead axis and, therefore, generates STE in that lead. The absence of LV hypertrophy by QRS voltage criteria, moreover, does not exclude this diagnosis, since patients with increased LV mass may exhibit repolarization abnormalities alone.

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours





August 13, 2012
Kenta Nakamura, MD; David M. Dudzinski, MD, JD
Arch Intern Med. 2012;172(15):1190-1191. doi:10.1001/archinternmed.2012.2732.
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Topics

The Rational Clinical Examination
Accuracy of ECG

The Rational Clinical Examination
Accuracy of Electrocardiography and Chest Radiography