ST Segment Elevation in aVR

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Luke O. -

There is a cutting cautionary tale in this. I have followed this STE in aVR story for some time and sometimes struggle with colleagues who are utterly convinced that it equals STEMI because of something they have heard on a podcast somewhere.

STE in aVR was never a STEMI equivalent in itself (without other very stringent criteria).

The corependium chapter cites two papers:
The 2018 Fourth Universal Definition of MI calls STE in aVR a STEMI equivalent in the summary on p2234 but elsewhere in the text it refers to the necessity of haemodynamic compromise for this pattern to suggest multivessel or L main disease.

The 2017 ESC guidelines advocate for emergent cath lab activation for this pattern, though the text includes the extra phrase about this pattern existing "particularly if haemodynamic compromise" [exists]. They cite one paper which is titled "Relationship of ST elevation in lead aVR with angiographic findings and outcome in **non-ST elevation** acute coronary syndromes" which concludes that STE in aVR has prognostic significance by itself but adds no prognostic value over GRACE score prognostication.

Other papers, not cited in the corependium chapter, require similar careful reading to not walk away with the "STE in aVR = STEMI" oversimplification. The 2013 ACCF/AHA STEMI guideline, as looked at by Steve Smith in the link below discusses this pattern as a sign of LMCA occlusion but 1. does not actually define this as STEMI and 2. Uses a paper (Jong et al) which erroneously referred to stenosis of >50% as occlusion (the referencing was done wrong too, not paper 9 but paper 11).

The ED FOAM / multimedia world, as much as it has added a huge amount to my career, really went to town on this STE in AVR pattern as a STEMI and generally failed to add all the fine details and caveats as above. At the 2012 Essentials of EM, the presenter tells a story of a well-ish looking 40-something lady (triage thought they had asthma) with minimal STE in AVR, some very mild STE across the precordium and the EM doctor managing to convince a reluctant cardiology fellow to take the patient to the cath lab by faxing through abstracts of papers about AVR to the CCU where the cardiology fellow was. Supposedly the patient had a LMCA occlusion, which is hard to believe knowing now what we know about this pattern.

The Steve Smith blog had a great write-up about STE in aVR way back in 2014, where he said it was not a STEMI equivalent in itself: . This is especially good when its appreciated how much the EM world was saying otherwise at the time.

This whole thing of people getting in the face of their cardiologists about STE in aVR is a bit of a face-palm thing. I don't mind specialists ripping on EM because of their own hubris but man, it sucks when their grounds to rip on EM are valid.

What I take away from this:
1. the boring minor details matter. If someone has a great simple rule that they are smug about, that no one else knows, check the references very very carefully. Really need to go full nerd mode on this.
2. there is a fine line between advocating for your patient and being uncivil towards specialists. If a difference of opinion can't be settled with a respectful conversation there is a real issue of professionalism somewhere, rather than a misunderstanding of medical science. At least that's how it is in the hospitals where I've worked.

Mel H. -

There are some great points here - caution with new information and some humility is always key! What is true today is not tomorrow.

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