RT Journal
A1 Nakamura K, Dudzinski DM
T1 ST-segment elevation in lead avr on the presenting electrocardiogram—reply
JF Archives of Internal Medicine
JO Archives of Internal Medicine
YR 2012
FD August 13
VO 172
IS 15
SP 1190
OP 1191
DO 10.1001/archinternmed.2012.2732
UL http://dx.doi.org/10.1001/archinternmed.2012.2732
AB 
We appreciate the thoughtful points raised by Dr Zema. We agree that left ventricular (LV) hypertrophy is another explanation for ST-segment elevation in lead aVR in addition to the diagnoses mentioned in our report.1 Indeed, an early case series studying the aV limb leads in the diagnosis of LV strain identified ST-segment changes in lead aVR as suggestive of LV strain in addition to the specific voltage criteria of S wave greater than 14 mm.2 Our reported patient did not have LV hypertrophy by either echocardiography or the electrocardiographic criteria used by Barrabés et al.3 In that study, the authors noted an increased frequency of LV hypertrophy in patients with ST-segment elevation in lead aVR and performed a subanalysis of the significance of ST-segment elevation in lead aVR only after excluding patients with LV hypertrophy.