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The aVR Sign as a Warning

doi: 10.1097/01.EEM.0000655032.38545.bc


    There is a perception that the aVr sign has much more import among emergency physicians than cardiologists. Understanding of it has evolved, with recent literature and expert cardiology opinion weighing in.

    The combination of multi-lead ST depression and ST elevation in lead aVR is the electrocardiographic aVR sign in patients presenting with signs and symptoms of an acute coronary syndrome. (J Electrocardiol. 2019;56:121.) The sign has been associated with severe left main or three-vessel coronary artery disease and a high risk of death.

    Some recent guidelines suggest that the aVR sign may represent a STEMI equivalent and is an indication for emergent cardiac catheterization and reperfusion. A recent study, however, found that aVR ST-segment elevation almost never signified total occlusion of the left main or LAD coronary arteries. (Am J Med. 2019;132[5]:622.

    If the clinical presentation is suggestive of ACS, the aVR sign can indicate severe left main or multivessel coronary artery stenosis but not acute thrombotic obstruction, so the aVR sign is not a STEMI equivalent. (J Electrocardiol. 2019;56:121.)

    The aVR sign is not specific for ACS. ECGs demonstrating the aVR sign have been recorded in patients with severe LVH, hemorrhagic shock, myocarditis, massive PE, type A aortic dissection, and SVT. (J Electrocardiol. 2019;56:121; Cardiol Clin. 2018;36[1]:13.)

    Regardless of its etiology, the aVR sign usually reflects a high-risk condition that warrants urgent evaluation and management. “If alternative causes have been ruled out, urgent, but not necessarily immediate, cardiac catheterization and reperfusion is warranted.” (J Electrocardiol. 2019;56:121.)

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