Let’s fight for lead aVR!!

2 Dic

Ok I know Amal Mattu already said that: Lead aVR gets no respect!

And to make a long story short, let’s go to the point!

Yesterday morning a very good friend of mine, 60 year old male, send me a photo of  the EKG he did as routine control, after a week or so of ongoing non specific (GERDS for his GP) symptoms

Precordial leads Marco

Precordial leads

Limb leads

Limb leads

His doctor said he had to do some other tests due to of EKG signs of LVH but my friend said I’m still not well so he called and sent me the photo of his EKG. 9.20 am.

I immediately  referred him to the local hospital (where I worked for over 10 years) where he arrived almost 1 hour later.

I called my coll on duty that morning and told him: have you seen ST in aVR? He answered me a little fuzzy and said let’s wait for the Troponin. First sign of no respect . Here is the EKG in ED.

ECG limb no pain

ECG Precordial no pain

Troponin arrived in 1 hour and the result was 0,02  (normal for our standards).

But what about aVR!!??

So I begged for a bedside echo that showed left ventricular hypertrophy and normal wall motion with good EF (my friend has a mild hypertension on BBlock). So aVR and ST depression were interpreted as sign o LVH.

Second Troponin 5 hours later still negative and still no symptoms. So I called the cardiologist (always on the phone I was on HEMS shift that day) with my “story” about aVR,  and he finally gave me credit, but he said: unfortunately no Troponin no symptoms no cath lab.

He was really concerned about the clinical history and the EKG and admitted my friend in ICU for follow up. 17,00 pm

At 17.49 pm my friend called the nurse cause of a chest discomfort, a bedside EKG was recorded and shown below

Precordial chest pain

Precordial chest pain

This time aVR became really important and the cath lab did his job more than 6 hours later: triple vessel disease, 3 STENT placed no complications good angiographic result.

Take home message: always lissen to the Guru, even in Florence!

Thanks Amal.


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