Management of Acute Coronary Syndrome with ST Segment Elevation aVR Leads in Hospitals with Limited Facilities

Abstract

Analysis of aVR leads on electrocardiography (ECG) is often given less attention, when in fact ST-segment elevation in aVR leads and diffuse ST-segment depression in other leads indicates circumferential subendocardial ischemia, which can be caused by left main coronary artery occlusion (LMCA) or three-vessel coronary artery disease (3VD) and is associated with a poor prognosis. An 83-year-old male came to the emergency room with chest pain for 18 hours. The ECG showed ST-segment elevation in the aVR with diffuse ST-segment depression in the anteroinferolateral leads. He was diagnosed with acute coronary syndrome (ACS), suspected occlusion of the left main coronary artery (LMCA), and a differential diagnosis of three-vessel coronary artery disease (3VD). Examination of cardiac markers and cardiac catheterization facilities were not available. A loading dose of aspirin and clopidogrel was given. During in-hospital treatment, ECG evaluation showed improvement of aVR ST-segment elevation. Early recognition of ACS with aVR ST-segment elevation and prompt early management are important.