Time is muscle, context is key: Re-evaluating the urgency of aVR ST elevation

Area of Science:

• Cardiology
• Emergency Medicine
• Diagnostic Imaging

Background:

• ST-segment elevation in lead aVR with diffuse ST depression is a recognized ECG pattern.
• This pattern is traditionally linked to acute coronary syndromes, specifically left main or three-vessel coronary artery disease.
• However, the diagnostic specificity of this ECG finding remains debated.

Purpose of the Study:

• To report a case where the characteristic ECG pattern was associated with type A aortic dissection.
• To emphasize the importance of considering differential diagnoses in patients with hemodynamic instability presenting with this ECG pattern.

Main Methods:

• Case report of a 60-year-old male with chest pain and hemodynamic shock.
• Electrocardiogram (ECG) interpretation revealing diffuse ST depression and ST elevation in lead aVR.
• Physical examination and echocardiography leading to suspicion of type A aortic dissection.
• Computed tomography (CT) scan confirming the diagnosis of type A aortic dissection.

Main Results:

• The patient presented with symptoms suggestive of acute coronary syndrome.
• The ECG findings prompted urgent cardiac catheterization.
• Diagnosis was ultimately type A aortic dissection, not coronary artery disease.
• This highlights the critical need for differential diagnosis.

Conclusions:

• The ECG pattern of ST elevation in lead aVR with diffuse ST depression is not exclusive to coronary artery disease.
• In patients with hemodynamic instability, this ECG finding necessitates a broad differential diagnosis.
• Type A aortic dissection should be considered in the differential diagnosis for this ECG presentation.