Journal Logo

EMedHome's Clinical Pearl

EMedHome's Clinical Pearl

The aVR Sign as a Warning

doi: 10.1097/01.EEM.0000655032.38545.bc

    BY EMEDHOME.COM

    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.)

    This Clinical Pearl first appeared on EMedHome.com. Subscribers receive a new clinical pearl emailed to them every Wednesday. Visitwww.EMedHome.com.

    EMedHome.com on EM-News.com

    Visit our website for videos and podcasts from Amal Mattu, MD, and other noted emergency physicians from EMedHome.com and EMedHome's video lectures at http://bit.ly/EMN-EMedHomeVideos.

    This Month's Video

    Laura Bontempo, MD: The 2019 Crashing Patient Conference: http://bit.ly/EMN-EMedHomeVideos. Dr. Bontempo is an assistant professor and the assistant director of faculty development and residency education of emergency medicine at the University of Maryland Medical Center.

    This Month's Podcast

    Amal Mattu, MD, and Colleagues: Critical Illness in the Elderly, Posterior Stroke, and Alcohol Withdrawal: http://bit.ly/MattuEMN. Dr. Mattu is one of the premier speakers in emergency medicine, and a professor of emergency medicine and the vice chair of emergency medicine at the University of Maryland School of Medicine in Baltimore.

    Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.