ST segment elevation in lead aVR during exercise testing is associated with LAD stenosis
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To evaluate, in patients with chest pain, the diagnostic value of ST elevation (STE) in lead aVR during stress testing prior to 99m Tc-sestamibi scanning correlating ischaemic territory with angiographic findings.
Consecutive patients attending for 99m Tc-sestamibi myocardial perfusion imaging (MPI) completed a treadmill protocol. Peak exercise ECGs were coded. STE ≥0.05 mV in lead aVR was considered significant. Gated perfusion images and findings at angiography were assessed.
STE in lead aVR occurred in 25% (138/557) of the patients. More patients with STE in aVR had a reversible defect on imaging compared with those who had no STE in aVR (41%, 56/138 vs 27%, 114/419, p=0.003). Defects indicating a left anterior descending artery (LAD) culprit lesion were more common in the STE in aVR group (20%, 27/138 vs 9%, 39/419, p=0.001). There was a trend towards coronary artery stenosis (>70%) in a double vessel distribution involving the LAD in those patients who had STE in aVR compared with those who did not (22%, 8/37 vs 5%, 4/77, p=0.06). Logistic regression analysis demonstrated that STE in aVR (OR 1.36, p=0.233) is not an independent predictor of inducible abnormality when adjusted for STD >0.1 mV (OR 1.69, p=0.026). However, using anterior wall defect as an end-point, STE in aVR (OR 2.77, p=0.008) was a predictor even after adjustment for STD (OR 1.43, p=0.281).
STE in lead aVR during exercise does not diagnose more inducible abnormalities than STD alone. However, unlike STD, which is not predictive of a territory of ischaemia, STE in aVR may indicate an anterior wall defect.
KeywordsMyocardial ischaemia Diagnostic techniques Cardiovascular Electrocardiography Radionuclide imaging Lead aVR
This work was completed with the invaluable assistance of Mrs. Helen Long, MSC, BSE, Chief Cardiac Physiologist and Dr. Chris Patterson, medical statistician. The authors have had full control of all primary data and we agree to allow the EJNMMI to review such data if requested.
- 3.Yamaji H, Iwasaki K, Kusachi S, Murakami T, Hirami R, Hamamoto H, et al. Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography: ST segment elevation in lead aVR with less ST segment elevation in lead V1. J Am Coll Cardiol 2001;38:1348–54.PubMedCrossRefGoogle Scholar
- 5.Gaitonde RS, Sharma N, Ali-Hasan S, Miller JM, Jayachandran JV, Kalaria VG. Prediction of significant left main coronary artery stenosis by the 12-lead electrocardiogram in patients with rest angina pectoris and the withholding of clopidogrel therapy. Am J Cardiol 2003;92:846–8.PubMedCrossRefGoogle Scholar
- 13.Kosuge M, Kimura K, Ishikawa T, Endo T, Hongo Y, Shigemasa T, et al. ST-segment depression in lead aVR predicts predischarge left ventricular dysfunction in patients with reperfused anterior acute myocardial infarction with anterolateral ST-segment elevation. Am Heart J 2001;142:51–7.PubMedCrossRefGoogle Scholar