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Normalization of Diffuse ST-Depression with aVR Elevation After Rehydration in a Patient with Severe Aortic Stenosis

Sachin R Patel1, Vikas J Patel1, Brittany Clark2

  • 1Department of Internal Medicine, Florida State University, College of Medicine, Tallahassee, FL, USA.

The American Journal of Case Reports
|May 23, 2017
PubMed

Insights

A unique ECG pattern of ST elevation in lead aVR and ST depression may mask myocardial infarction. Prompt cardiac evaluation is crucial, even if symptoms temporarily improve with rehydration.

Area of Science:

  • Cardiology
  • Electrocardiography
  • Critical Care Medicine

Background:

  • The electrocardiogram (ECG) finding of isolated ST elevation in lead aVR with diffuse ST depression is a recognized pattern.
  • This unique ECG pattern is linked to various diagnoses, including acute coronary syndromes and left main coronary artery disease.
  • Prompt and thorough cardiac evaluation is essential when this ECG pattern is observed.

Observation:

  • A 53-year-old male presented with altered mental status, hypotension, and tachycardia.
  • Initial ECG revealed diffuse ST depression with isolated ST elevation in lead aVR; troponin levels were negative.
  • Following rehydration, the ECG normalized, but echocardiography showed severe aortic stenosis and global hypokinesis.

Findings:

  • Repeat troponin levels became elevated, and the patient experienced cardiac arrests.
  • Cardiac catheterization revealed occluded coronary arteries (right coronary artery and LAD).
  • Despite interventions including coronary artery bypass grafting and aortic valve replacement, the patient died from massive myocardial infarction.

Implications:

  • The normalization of ST depression and ST elevation in aVR after fluid resuscitation can obscure a stuttering myocardial infarction.
  • This case highlights the importance of considering severe underlying cardiac pathology despite transient ECG improvement.
  • Aggressive cardiac evaluation and management are critical for patients presenting with this specific ECG pattern and hemodynamic instability.

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