Lead avR in STEMI & NSTEMI

Why is STE in lead avR important?

1) Increased mortality with this finding

2) Avoid thienopyridine (e.g., clopidogrel) administration in such patients who are likely to need CABG


  • STE in aVR of at least 0.5 mm in anterior STEMI predicts septal AMI (occlusion of the LAD proximal to the first septal perforator)
  • STE in aVR is negatively correlated with a long (vs. short), or wraparound, LAD that affected the inferior wall.
  • This is intuitive, as a proximal occlusion would lead to basal wall STEMI, and distal occlusion of a wraparound (long, “type III”) LAD would lead to inferior STE which would reciprocally attenuate the STE in aVR, or lead to STD in aVR.
  • avR STE means LMCA occlusion?
    – Most of the patients with LMCA occlusion do not survive to cath lab.
    – ECG picture in LMCA occlusion = anterior STEMI + high lateral STEMI. avR STE is due to transmural infarction of the basal wall, not reciprocal to STD in other leads (STE is indicative of direct injury).
    – STE in avR > V1 does not always predict LMCA occlusion.


  • Diffuse ST depression has a good PPV and NPV for 3-vessel and left main disease (not occlusion!)
  • The degree of STE in aVR, though not independent of ST depression, has strong association with outcome independent of clinical factors such as Killip class and blood pressure.
  • STE in avR in this case is reciprocal to STD in other leads and due to subendocardial ischemia due to left main INSUFFICIENCY !

Learning points

  1. avR is important. STE in avR in both STEMI and NSTEMI gives a poor prognosis.
  2. Avoid thienopyridine (prasugrel, clopidogrel) in patients presenting with avR ST elevation. They will likely need CABG and these drugs will increase the bleeding risk.

Reference: http://hqmeded-ecg.blogspot.my/2014/08/the-difference-between-left-main.html



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