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
 Precordial
Limb Leads
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
8
to ICU
Hours Later
 Cardiogenic
 Died
Shock

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
 Patient
to Cath Lab
 Returned
 “Not
Paged and to ER
15 Minutes Later
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
 STE
aVr
 STE aVl
STD

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
 STE
delta waves on post conversion EKG
& 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

LBBB and rightward axis
>90°

Positive QRS
concordance

RBBB and QRS > 0.14
secs
QRS axis between –90 °
and +180°

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
 andrewj.bowman@gmail.com
 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
EKG’s

hqmeded-ecg.blogspot.com

ecgguru.com

en.ecgpedia.org
Lots of
Dr. Smith
Free Downloads
Comprehensive Overview