ST↑ in aVR: un’alterazione di tutto rispetto

16 Apr

homer_the_scream

Qualche mese fa MEDEST ha pubblicato un post in merito ad un caso clinico in cui un ECG con alterazione del tratto ST in aVR era stato trascurato per un atteggiamento di diffusa sufficienza con cui molti clinici guardano alle alterazioni presenti in questa derivazione.

Approfittiamo di questo ECG, registrato ieri a domicilio in un paziente di con dolore toracico, per puntualizzare alcuni concetti fondamentali riguardo alle alterazioni del tratto ST in aVR:

STE aVR_c

Click to enlarge/Clicca per ingrandire

  • L’elevazione del tratto in ST↑ ≥1 mm in aVR, nel contesto di diffuse alterazioni ischemiche (ST↓), è un segno ischemico molto grave, patognomonico per occlusione del tronco comune (LMCA), della discendente anteriore (LAD) o di malattia dei tre vasi (3VD)
  • I pazienti con ST↑ ≥1 mm in aVR e clinica tipica devono essere sottoposti PTCA in urgenza
  • L’assenza di ST↑ in aVR esclude con molta accuratezza la probabilità di occlusione del tronco comune
  • I criteri sopra esposti non sono applicabili in caso di TPSV o in assenza di segni clinici di ischemia
  • ST ↑ in aVR+ST↑ in aVL indicano occlusione del tronco comune (LMCA)
  • ST ↑ in aVR+ST↑ in V1 indicano occlusione del tronco comune (LMCA) o della discendente anteriore (LAD)
    • ST ↑ in aVR >ST↑ in V1 fa sospettare l’occlusione del tronco comune (LMCA) piuttosto che quello della discendente anteriore (LAD)
  • ST↑ in aVR ≥ 1mm è associato con un aumento fino a 6 volte della mortalità
  • ST↑ in aVR ≥ 1.5mm è associato ad una mortalità che può andare dal 25% al 70%

In conclusione aVR merita più considerazione, perchè il rilievo di ST↑ in questa derivazione indica lesioni a carico di vasi motlo critici per la circolazione coronarica e la prognosi di questi pazienti è altamente sfavorevole.

MEDEST you tube

 

 

 

References:

  1. aVR the forgotten lead
  2. ST Elevation in aVR – LMCA occlusion?
  3. aVR The Neglected Lead
  4. Williamson K, Mattu A, Plautz CU, et al. Electrocardiographic applications of lead aVR. Am J Emerg Med. 2006 Nov;24(7):864-74
  5. Rokos IC, French WJ, Mattu A, et al. Appropriate cardiac cath lab activation: optimizing the electrocardiogram interpretation and clinical decision making for acute ST-elevation myocardial infarction. Am Heart J. 2010 Dec; 160(6):995-1003
  6. Nikus KC, Eskola MJ. Electrocardiogram patterns in acute left main coronary artery occlusion. J Electrocardiology. 2008 Nov-Dec;41(6):626-9
  7. Kosuge M, Ebina T, Hibi K, et at. An early and simple predictor of severe left main and/or three-vessel disease in patients with non-ST-segment elevation acute coronary syndrome. Am J Cardiol. 2011 Feb 15;107(4):495-500
  8. Nikus K, Pahlm O, Wagner G, et al. Electrocardiographic classification of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology. 2010 Mar-Apr;43(2):93, 97-98
 

 

Tag:, ,

Lascia un commento

Questo sito utilizza Akismet per ridurre lo spam. Scopri come vengono elaborati i dati derivati dai commenti.

CriticalCareNow

Emergenza-Urgenza 2.0

ALL Ohio EM

Supporting ALL Ohio EM Residencies in the #FOAMed World

Triggerlab

Let's try to make it simple

thinking critical care

a blog for thinking docs: blending good evidence, physiology, common sense, and applying it at the bedside!

urgentcareultrasound

More definitive diagnosis, better patient care

MLR

Critical Care Northampton

Reviewing Critical Care, Journals and FOAMed

OHCA research

Prehospital critical care for out-of-hospital cardiac arrest

SonoStuff

Education and entertainment for the ultrasound enthusiast

phemcast

A UK PREHOSPITAL PODCAST

First10EM

Emergency medicine - When minutes matter...

Songs or Stories

Sharing the Science and Art of Paediatric Anaesthesia

airwayNautics

"Live as if you will die tomorrow; Learn as if you will live forever"

resusNautics

Navigating resuscitation

emDocs

The Collective

A Hive Mind for Prehospital and Retrieval Med

Dave on Airways

Thoughts and opinions on airways and resuscitation science

FOAMcast

A Free Open Access Medical Education Emergency Medicine Core Content Mash Up

Broome Docs

Rural Generalist Doctors Education

St.Emlyn's

Emergency Medicine #FOAMed

BoringEM

"CardioOnline"Basic and Advanced Cardiovascular medicine" Cariology" concepts and Review -Dr.Nabil Paktin,MD.FACC.دکتـور نبــــیل "پاکطــــین

این سایت را به آن دکتوران و محصلین طب که شب و روز برای رفاه نوع انسان فداکاری می کنند ، جوانی و لذایذ زندگی را بدون چشمداشت به امتیاز و نفرین و آفرین قربان خدمت به بشر می کنند و بار سنگین خدمت و اصلاح را بدوش می کشند ، اهداء می کنم This site is dedicated to all Doctors and students that aver the great responsibility of People’s well-being upon their shoulders and carry on their onerous task with utmost dedication and Devotionاولین سایت و ژورنال انتــرنتی علـــمی ،تخـصصی ، پــژوهشــی و آمــوزشــی طبـــی در افغــانســـتان

DOWNSTAIRS CARE OUT THERE BLOG

PHARM, #FOAMed

EmergencyPedia

Free Open Access Medical Education

Little Medic

Learning everything I can from everywhere I can. This is my little blog to keep track of new things medical, paramedical and pre-hospital from a student's perspective.

Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds

In memory of Dr John Hinds

Prehospital Emergency Medicine Blog

All you want to know about prehospital emergency medicine

Italy Customized Tour Operator in Florence

Check out our updated blog posts at https://www.italycustomized.it/blog

GoogleFOAM/FOAMSearch

The FOAM Search Engine

EM Lyceum

where everything is up for debate . . .

Pediatric EM Morsels

Pediatric Emergency Medicine Education

KidsCareEverywhere

EM Pills

AmboFOAM

Free Open Access Medical Education for Paramedics

Rural Doctors Net

useful resources for rural clinicians

Auckland HEMS

Unofficial site for prehospital care providers of the Auckland HEMS service

ECHOARTE

L'ECOGRAFIA: ENTROPIA DELL'IMMAGINE

MEDEST

Prehospital Emergency Medicine

EM Basic

Your Boot Camp Guide to Emergency Medicine

KI Doc

WE HAVE MOVED - VISIT WWW.KIDOCS.ORG FOR NEW CONTENT

Emergency Live

Prehospital Emergency Medicine

AMP EM

Academic Medicine Pearls in Emergency Medicine from THE Ohio State University Residency Program

Prehospital Emergency Medicine

 Academic Life in Emergency Medicine

Prehospital Emergency Medicine

Comments on: Homepage

Prehospital Emergency Medicine

Greater Sydney Area HEMS

The Pre-Hospital & Retrieval Medicine Team of NSW Ambulance