EKG Lead aVr

2. EKG Lead aVr: What You
DON’T Know May Kill Your
Patient

3. EKG Lead aVr: What You
DON’T Know May Kill Your
Patient
Andrew J. Bowman
Acute Care Nurse Practitioner
Fellow American College CV
Nurses
Emergency Departments
Witham Health Services -
Lebanon
IU Health Arnett - Lafayette

4. Disclosures
•No financial disclosures

5. EKG Club
•Co-Founder
•Facebook – 1500+ (1800+ as of today)

6. History EKG
•First recorded 1887 – Waller
•Clinical tool - Einthoven

7. Einthoven’s EKG

8. Leads
•Limb Leads
•Augmented Limb Leads
•Precordial Leads

9. Limb Leads & Augmented Limb
Leads

10. Einthoven’s Triangle

11. Normal Ventricular Axis

13. Limb Leads
•I
•II
•III

14. Augmented Limb Leads
•aVr
•aVl
•aVf

15. Precordial Leads
•V1
•V2
•V3
•V4
•V5
•V6

16. Normal EKG

17. “Map’ of EKG

18. “Map’ of EKG

19. “Map’ of EKG
??
?

20. “Map” of EKG

21. Analogy

22. Anterior

23. Lateral

24. Lead aVr (or How Many View It)

25. Why EKG?
•Cardiac Problems
• Non-Cardiac Problems

26. Cardiac Problems
•Ischemia
•Injury
•Infarction
•Arrhythmia
•Cardiomyopathy

27. Non-Cardiac Problems
•Electrolyte Disorders
•Toxidromes
•Pulmonary Embolism

28. Lead aVr
•An augmented limb lead placed on right
arm
•Most commonly used to assure proper
limb lead placement
•Common belief rarely offers useful
information “forgotten 12
th
lead”

29. “Forgotten 12
th
Lead”
11

30. Lead aVr
•Actual several good reasons to carefully
evaluate lead aVr

31. Lead aVr
•STEMI / STEMI Equivalent
•SVT r/t WPW
•VT vs. SVT in WCT
•Pericarditis
•Na+ Channel Blocker Toxicity

32. STEMI
•ST segment Elevation Myocardial
Infarction
–A need to recognize pattern indicating acute
myocardial infarction and need for emergent
reperfusion therapies (PCI preferred)

33. STEMI Patterns to Know
•Inferior
•Lateral
•Septal
•Anterior
•Posterior

34. STEMI Patterns to Know

35. STEMI Patterns to Know

36. Inferior STEMI

37. Lateral STEMI

38. Anterior-Septal STEMI

39. Inferior-Posterior STEMI

40. How is aVr Helpful in STEMI?

41. Case
•64 year old man
•Hx MI, HTN, DM
•Left arm pain

42. Case EKG

43. What Do We See?

44. Case Progression
•ACS
•Widespread ST depression (STD)
–STE aVr & aVl & V1
•ASA
•NTG
•Heparin

45. Case Evolution
•Admitted to ICU
•8 Hours Later
•Cardiogenic Shock
•Died

46. STE Lead aVr
•In setting of ACS, STE Lead aVr
–LMCA Stenosis
–Proximal LAD Stenosis
–Triple Vessel Disease
–All BAD!!!!

47. STE Lead aVr
•STE aVr + aVl = LMCA Stenosis

48. STE Lead aVr
•STE aVr + aVl = LMCA Stenosis
•STE aVr > STE V1 = LMCA Stenosis

49. STE Lead aVr
•STE aVr + aVl = LMCA Stenosis
•STE aVr > STE V1 = LMCA Stenosis
•Greater STE aVr, more likely LMCA
Stenosis

50. ACS with LMCA Stenosis
•HIGH Mortality w/o PCI
•Medical Tx Does NOT Help!!

51. My Recent Case
•47 yowm
•Chest pain and heart racing 1 hr PTA
•**Sweating**
•Hx smokes, HTN
•No Known CAD

52. Initial EKG

54. Initial Evaluation
•P - 178
•R - 24
•BP - 260/180
•SpO2 – 95%
•Pain – 2/10
•Given ASA, IV Cardizem
•Repeat EKG

55. EKG 2

56. Evolution
•HR Better
•Still CP 2/10
•NTG with Better BP
•EKG Repeated

57. EKG 3

59. Evolution 2
•Concern for STEMI or Equivalent
•Diffuse STD
•STE aVr
•STE V1
•Concern for “BADNESS”

60. Evolution 2
•Interventionalist Paged and to ER
•Patient to Cath Lab
•Returned 15 Minutes Later
•“Not STEMI” “LVH”

61. Evolution 3
•Initial Troponin 0.14 (0.10)
•Admitted
•AM Troponin 13.3!!
•Cath Lab

62. Cath Lab
•Triple Vessel Disease

63. Cath Lab
•Triple Vessel Disease
–“BADNESS”

64. Why Delay?
•Cardiologists are often behind the times
•Large percentage of STEMI EKG
literature is from EM
•We have to “convince” cardiology

65. Next Case
•85 yowm
•Chest Pain
•EKG

66. EKG

67. What Do We See?
•Widespread STD
•STE aVr
•STE aVl

68. Evolution
•Elevated Troponin
•Dx NSTEMI
•Admitted
•Continued to Have Pain!

69. Repeat EKG

70. STE aVr + deWinter ST-T

71. Lead aVr in STEMI
•In setting of ACS, STE Lead aVr
–LMCA Stenosis
–Proximal LAD Stenosis
–Triple Vessel Disease
–All BAD!!!!

72. How Else Is aVr helpful?

73. SVT w WPW

74. SVT with WPW
•14 yowm
•Dizziness
•Healthy
•Exam – Tachycardia
•EKG

75. EKG

76. SVT

77. SVT

78. SVT
•STE Lead aVr with NCT likely to be WPW
•Confirm delta waves on post conversion
EKG
•STE & STD in SVT are not Dx ischemia

79. How Else May We Use aVr?

80. VT vs SVT in WCT

81. Numerous Old Algorithms
•Brugada Criteria
•Wellens Criteria
•Akhtar Criteria
•Griffith Criteria

82. Brugada Criteria
•4 step process
–No RS complex all precordial leads?
–RS interval > 100ms in 1 precordial lead?
–AV dissociation?
–Morphology criteria for VT present in
precordial leads V1-2 and V6?

83. Wellens Criteria
•QRS width > 0.14 secs
•Left axis deviation > -30°
•AV Dissociation
•Certain QRS configurations
–RBBB type QRS
•Monophasic R, qR, QR, RS in V1
•R/S < 1, monophasic R, QR, QS in V6
–LBBB type QRS
•qR or Qs in V6

84. Akhtar Criteria
•AV Dissociation
•Positive QRS
concordance
•QRS axis between
–90° and +180°
•LBBB and rightward
axis >90°
•RBBB and QRS > 0.14
secs
•LBBB and QRS > 0.16
secs
•QRS morphology
during tachycardia
different from baseline
preexisting BBB

85. Griffith Criteria
•SVT diagnosed only if QRS
morphology is typical of a BBB
–RBBB
•rSR’ in V1 and RS in V6 with R/S > 1
–LBBB
•rS or QS in V1 and V2 and delay to S nadir
< 70 msecs
•R wave and no Q wave in V6

86. What Makes It Easy?

87. Old EKG!

88. New Algorithm
•Uses a SINGLE EKG lead

89. VT vs SVT Lead aVr
(Verecki et al, January 2008, Heart Rhythm, 5/1)

90. WCT + SVT

91. WCT = VT

92. WCT = VT

93. Notched QS = VT

94. What Else is aVr Helpful For?

95. Pericarditis
•Diffuse “global” STE or STD
•PR segment depression inferior leads
•PR segment elevation aVr

96. Pericarditis

97. Pericarditis

98. Pericarditis

99. Pericarditis

100. Finally, What Else?

101. Na+ Channel Blocker Toxicity
•Amitriptyline
•Chlorimipramine
•Desipramine
•Doxepin
•Imipramine
•Nortriptyline
•Protriptyline
•Elavil
•Clomipramine
•Norpramin
•Sinequan
•Tofranil
•Pamelor
•Vivactil

102. TCA OD Effects
•AMS
•Hypotension
•Tachycardia
•Prolonged QRS, QTc
•Seizures
•Cardio-Respiratory Arrest

103. Terminal R Wave

104. TCA OD

105. TCA OD

106. TCA OD

107. TCA OD

108. Poorly Responsive Young Male

109. After Tx

110. TCA OD and What Else??

111. TCA “SALT”
•Shock
•AMS
•Long QRS & QTc
•Terminal R in Lead aVr
•“SALT” is also the cure NaHCO3

112. Lead aVr
•May be VERY helpful in…
–STEMI
–SVT r/t WPW
–VT vs SVT in WCT
–Pericarditis
–TCA OD

113. Handout
•Thanks to Michelle Lin, MD
•Academic Life in Emergency Medicine
–ALiEM
–academiclifeinem.com
•Paucis Verbis cards

114. Questions
•[email protected]
•Facebook “EKG Club”
–Add your “cool” EKG’s and stump us

115. Web Sites
•ekgumem.tumblr.com Dr. Mattu’s
•ecg.bidmc.harvard.edu/maven Lots of
EKG’s
•hqmeded-ecg.blogspot.com Dr. Smith
•ecgguru.com Free Downloads
•en.ecgpedia.org Comprehensive
Overview