Journal of Electrocardiology 54 (2019) 10–12

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Journal of Electrocardiology

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Diffuse ST segment depression and ST segment elevation in lead aVR and

a r t i c l e i n f o a b s t r a c t

Keywords: The current guidelines for resting electrocardiograms of diffuse ST segment depression coupled with ST segment
Diffuse ST depression elevation in aVR and/or V1 that are otherwise unremarkable indicate multivessel or left main coronary artery ob-
Lead aVR struction. However, our case meets the above electrocardiogram changes, but involves left circumflex artery
Left circumflex coronary artery
occlusion.
Left main coronary artery
© 2019 Elsevier Inc. All rights reserved.

Case report [1]. Although, the characteristic ECG of our patient met the criteria, it in-
volved proximal LCX acute subtotal occlusion.
A 73-year-old man was admitted to the emergency department with Lead aVR points to the left ventricular cavity and has a frontal plane
repeated chest pain, diaphoresis, and vomiting. He had neither a history vector of −150°; diffuse subendocardial ischaemia or posterobasal in-
of hypertension or diabetes nor any family history of coronary artery farction produces a current of injury that is directed at aVR, leading to
disease. His symptoms persisted for 14 h and were aggravated for 2 h. ST segment elevation. When the LCX, which supplies the posterobasal
On clinical examination, his blood pressure was 167/93 mm Hg and area, is occluded, it can lead to aVR ST elevation. Due to different ana-
heart rate was 60 beats per minute; he showed normal heart sounds tomical locations, the mean vector produced by LCX occlusion is more
with no murmurs, and no jugular venous distention. The first electro- biased towards the reverse extension line of lead II than the LMCA.
cardiogram (ECG) was performed in the emergency department Thus, no ST depression in aVL is a clue to differentiate LCX occlusion
(Fig. 1A). His troponin I level was 0.088 ng/mL (normal value: from LMCA occlusion. A report by Thrudeep et al. also supports this
0.010–0.023); thus, he was diagnosed with acute coronary syndrome view [2]. In addition, based on analysis of the precordial leads, the first
non-ST segment elevation myocardial infarction (non-STEMI) and ECG of our patient shows that the amplitude of R in V1 was 3.8 mm
underwent emergency coronary angiography that revealed acute sub- and R/S amplitude ratio was 0.52. The infarction vector of the
total occlusion of the proximal left circumflex artery (LCX) and 50% ste- ‘posterobasal’, which is due to LCX occlusion, would face the positive
nosis in the left anterior descending artery (Fig. 2). He then underwent poles of leads V1 and V2, producing ‘Q-wave-equivalent’ pathologically
percutaneous coronary intervention (PCI) in the LCX using a 2.75 × 23- increased R waves. A report by de Luna AB et al. suggests that an R/S am-
mm stent. The ECG was recorded after the procedure (Fig. 1B). plitude ratio of 0.5 or greater and amplitude of R in V1 of N3 mm are very
specific criteria for locating culprit vessels in the LCX [3].

Discussion Conclusion

According to the 2017 European Society of Cardiology guidelines for With the findings of the present clinical case, we suggest that ST de-
the management of acute myocardial infarction in patients presenting pression in multi-lead ECG, elevation in lead aVR N V1 with no ST de-
with ST-segment elevation, ST depression ≥1 mm in 8 or more surface pression in aVL, R/S N0.5 or amplitude of R N3 mm in V1 may be clues
leads, coupled with ST-segment elevation in aVR and/or V1, suggests to differentiate LMCA occlusion from LCX occlusion.
left main coronary artery (LMCA) obstruction or severe vessel ischaemia
Acknowledgements
⁎ Corresponding author at: No 1. Chengbei Road, Jiading District, Shanghai, China.
E-mail address: [email protected] (X. Xu). None.

https://doi.org/10.1016/j.jelectrocard.2019.02.004
0022-0736/© 2019 Elsevier Inc. All rights reserved.
 Y. Lin et al. / Journal of Electrocardiology 54 (2019) 10–12
Fig. 1. (A) The first electrocardiogram shows ST elevation in aVR (2.0 mm) N V1 (1.5 mm) with ST depression N1 mm in eight leads, and no ST depression in aVL. (B) Post-procedure percutaneous coronary intervention electrocardiogram shows
resolution of ST elevation. (C) The lesion vector (black arrow) in frontal, vector localization (brown zone) of high lateral infarction in isolated proximal left circumflex artery (LCX) occlusion. (D) The lesion vector (black arrow) in horizontal.

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12 Y. Lin et al. / Journal of Electrocardiology 54 (2019) 10–12

Fig. 2. (A) Coronary angiogram showing an acute subtotal occlusion of the proximal left circumflex artery (LCX). (B) Coronary angiogram after LCX stenting, showing thrombolysis in
myocardial infarction (TIMI; 3-flow).

Funding sources with ST-segment elevation: the task force for the management of acute myocardial
infarction in patients presenting with ST-segment elevation of the European Society
of Cardiology (ESC). Eur Heart J 2017;2018(39):119–77.
There were no sources of funding for this work. [2] Thrudeep S, Geofi G, Rupesh G, Abdulkhadar S. Dilemma of localization of culprit ves-
sel by electrocardiography in acute myocardial infarction. Indian Heart J 2016;68
(Suppl. 2):S15–7.
Conflicts of interest [3] de Luna AB, Cino J, Goldwasser D, Kotzeva A, Elosua R, Carreras F, et al. New electro-
cardiographic diagnostic criteria for the pathologic R waves in leads V1 and V2 of an-
None. atomically lateral myocardial infarction. J Electrocardiol 2008;41:413–8.

References
[1] Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al. ESC
guidelines for the management of acute myocardial infarction in patients presenting