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Augmented Vector Right ST-Segment Elevation: Pearls and Pitfalls

Published:January 21, 2021DOI:https://doi.org/10.1016/j.nurpra.2020.12.010

      Highlights

      • Five clinical pearls for augmented vector right (aVR) ST-segment elevation (STE) are presented.
      • A mnemonic for differential diagnosis in nonocclusve aVR STE is discussed.
      • A brief review of the evolving literature on the high mortality rate associated with aVR STE is provided.

      Abstract

      ST-segment elevation myocardial infarction (STEMI) is characterized by ST-segment elevation in at least 2 contiguous leads, chest discomfort, and the release of biomarkers requiring emergent revascularization. In 2013, the American College of Cardiology Foundation/American Heart Association revised STEMI guidelines to include augmented vector right (aVR) ST-segment elevation to be treated as a STEMI equivalent. However, aVR ST-segment elevation with multilead ST depression can occur in presentations other than occlusive myocardial infarctions. The purpose of this clinical feature is to provide a brief review of aVR ST-segment elevation, explore approaches to clinical decision making, and provide tools to support nurse practitioners caring for patients with cardiac issues.

      Keywords

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      References

        • O'Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2013; 61: e78-e140https://doi.org/10.1161/CIR.0b013e3182742cf6
        • Knotts R.J.
        • Wilson J.M.
        • Kim E.
        • Huang H.D.
        • Birnbaum Y.
        Diffuse ST depression with ST elevation in aVR: is this pattern specific for global ischemia due to left main coronary artery disease?.
        J Electrocardiol. 2013; 46: 240-248
        • Kosuge M.
        • Ebina T.
        • Hibi K.
        • et al.
        ST-segment elevation resolution in lead aVR: a strong predictor of adverse outcomes in patients with non-ST-segment elevation acute coronary syndrome.
        Circ J. 2008; 72: 1047-1053
        • Riera A.R.
        • Ferreira C.
        • Filhos C.F.
        • et al.
        Clinical value of lead aVR.
        Ann Noninvasive Electrocardiol. 2011; 16: 295-302
        • Patel S.R.
        • Patel V.J.
        • Clark B.
        • Rust G.
        Normalization of diffuse ST-depression with aVR elevation after rehydration in a patient with severe aortic stenosis.
        Am J Case Rep. 2017; 18: 563-567https://doi.org/10.12659/ajcr.902510
        • Barrabés J.A.
        • Figueras J.
        • Moure C.
        • et al.
        Prognostic value of lead aVR in patients with a first non-ST-segment elevation acute myocardial infarction.
        Circulation. 2003; 108: 814-819
        • de Winter R.J.
        • Verouden N.J.
        • Wellens H.J.
        • Wilde A.A.
        A new ECG sign of proximal LAD occlusion.
        N Engl J Med. 2008; 359: 2071-2073
        • Jong G.P.
        • Ma T.
        • Chou P.
        • Shyu M.Y.
        • Tseng W.K.
        • Chang T.C.
        Reciprocal changes in 12-lead electrocardiography can predict left main coronary artery lesion in patients with acute myocardial infarction.
        Int Heart J. 2006; 47: 13-20
        • D’Ascenzo F.
        • Presutti D.G.
        • Picardi E.
        • et al.
        Prevalence and non-invasive predictors of left main or three-vessel coronary disease: evidence from a collaborative international meta-analysis including 22 740 patients.
        Heart. 2012; 98: 914-919
        • Russo G.
        • Ravenna S.E.
        • De Vita A.
        • et al.
        Exercise test predictors of severe coronary artery disease: role of ST-segment elevation in lead aVR.
        Clin Cardiol. 2017; 40: 102-108
        • Harhash A.A.
        • Huang J.J.
        • Reddy S.
        • et al.
        aVR ST segment elevation: acute STEMI or NOT? Incidence of an acute coronary occlusion.
        Am J Med. 2019; 132: 622-630
        • Beyranvand M.R.
        • Piranfar M.A.
        • Mobini M.
        • Pishgahi M.
        The relationship of ST segment changes in lead aVR with outcomes after myocardial infarction; a cross sectional study.
        Emerg (Tehran). 2017; 5: 1-8
        • Szymanski F.M.
        • Grabowski M.
        • Filipiak K.J.
        • Karpinski G.
        • Opolski G.
        Admission ST-segment elevation in lead aVR as the factor improving complex risk stratification in acute coronary syndromes.
        Am J Emerg Med. 2008; 26: 408-412
        • Chun A.A.
        • McGee S.
        Bedside diagnosis of coronary artery disease: a systematic review.
        Am J Med. 2004; 117: 334-343
        • Gokhroo R.K.
        • Ranwa B.L.
        • Kishor K.
        • et al.
        Sweating: a specific predictor of ST-segment elevation myocardial infarction among the symptoms of acute coronary syndrome: Sweating In Myocardial Infarction (SWIMI) Study Group.
        Clin Cardiol. 2016; 39: 90-95
        • Mokhtari A.
        • Dryver E.
        • Soderholm M.
        • Ekelund U.
        Diagnostic values of chest pain history, ECG, troponin and clinical gestalt in patients with chest pain and potential acute coronary syndrome assessed in the emergency department.
        Springerplus. 2015; 4: 219https://doi.org/10.1186/s40064-015-0992-9
        • Larson D.
        • Menssen K.M.
        • Sharkey S.W.
        • et al.
        “False positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction.
        JAMA. 2007; 298: 2754-2760

      Biography

      All authors are affiliated with the Department of Cardiac Sciences, Alberta Health Services in Calgary, Alberta, Canada. Jessica D. Jenkins, MN NP, is a nurse practitioner and can reached at [email protected] Margaret Henninger, MN NP, Mikaela J. Robertson, MN NP, Adrienne Rommens, MN NP, Lisa N. Wieler, MN NP, and Nancy M. Clark, MN NP, are nurse practitioners.