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EKG Lead aVr
The document discusses the importance of evaluating EKG lead aVr, as abnormalities in this lead can provide crucial information about cardiac conditions. It describes how ST elevation in aVr can indicate left main coronary artery stenosis or proximal LAD stenosis. ST elevation in aVr greater than V1 makes left main stenosis more likely. It also discusses how aVr can help in diagnosing SVT with WPW, distinguishing VT from SVT in wide complex tachycardia, identifying pericarditis, and sodium channel blocker toxicity. Evaluating aVr is important for prompt diagnosis and treatment of potentially life-threatening conditions.
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 financialdisclosures
- 5. EKG Club • Co-Founder •Facebook – 1500+ (1800+ as of today)
- 6. History EKG • Firstrecorded 1887 – Waller • Clinical tool - Einthoven
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- 8. Leads • Limb Leads •Augmented Limb Leads • Precordial Leads
- 9. Limb Leads &Augmented Limb Leads
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- 13. Limb Leads • I •II • III
- 14. Augmented Limb Leads •aVr • aVl • aVf
- 15. Precordial Leads • V1 •V2 • V3 • V4 • V5 • V6
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- 24. Lead aVr (orHow Many View It)
- 25. Why EKG? • CardiacProblems • Non-Cardiac Problems
- 26. Cardiac Problems • Ischemia •Injury • Infarction • Arrhythmia • Cardiomyopathy
- 27. Non-Cardiac Problems • ElectrolyteDisorders • Toxidromes • Pulmonary Embolism
- 28. Lead aVr • Anaugmented limb lead placed on right arm • Most commonly used to assure proper limb lead placement • Common belief rarely offers useful information “forgotten 12th lead”
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- 30. Lead aVr • Actualseveral 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 segmentElevation Myocardial Infarction – A need to recognize pattern indicating acute myocardial infarction and need for emergent reperfusion therapies (PCI preferred)
- 33. STEMI Patterns toKnow • Inferior • Lateral • Septal • Anterior • Posterior
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- 40. How is aVrHelpful in STEMI?
- 41. Case • 64 yearold man • Hx MI, HTN, DM • Left arm pain
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- 43. What Do WeSee?
- 44. Case Progression • ACS •Widespread ST depression (STD) – STE aVr & aVl & V1 • ASA • NTG • Heparin
- 45. Case Evolution • Admittedto 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 LMCAStenosis • 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
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- 54. Initial Evaluation • P- 178 • R - 24 • BP - 260/180 • SpO2 – 95% • Pain – 2/10 • Given ASA, IV Cardizem • Repeat EKG
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- 56. Evolution • HR Better •Still CP 2/10 • NTG with Better BP • EKG Repeated
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- 59. Evolution 2 • Concernfor STEMI or Equivalent • Diffuse STD • STE aVr • STE V1 • Concern for “BADNESS”
- 60. Evolution 2 • InterventionalistPaged and to ER • Patient to Cath Lab • Returned 15 Minutes Later • “Not STEMI” “LVH”
- 61. Evolution 3 • InitialTroponin 0.14 (0.10) • Admitted • AM Troponin 13.3!! • Cath Lab
- 62. Cath Lab • TripleVessel Disease
- 63. Cath Lab • TripleVessel Disease –“BADNESS”
- 64. Why Delay? • Cardiologistsare often behind the times • Large percentage of STEMI EKG literature is from EM • We have to “convince” cardiology
- 65. Next Case • 85yowm • Chest Pain • EKG
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- 67. What Do WeSee? • Widespread STD • STE aVr • STE aVl
- 68. Evolution • Elevated Troponin •Dx NSTEMI • Admitted • Continued to Have Pain!
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- 70. STE aVr +deWinter ST-T
- 71. Lead aVr inSTEMI • In setting of ACS, STE Lead aVr – LMCA Stenosis – Proximal LAD Stenosis – Triple Vessel Disease – All BAD!!!!
- 72. How Else IsaVr helpful?
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- 74. SVT with WPW •14 yowm • Dizziness • Healthy • Exam – Tachycardia • EKG
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- 78. SVT • STE LeadaVr with NCT likely to be WPW • Confirm delta waves on post conversion EKG • STE & STD in SVT are not Dx ischemia
- 79. How Else MayWe Use aVr?
- 80. VT vs SVTin WCT
- 81. Numerous Old Algorithms •Brugada Criteria • Wellens Criteria • Akhtar Criteria • Griffith Criteria
- 82. Brugada Criteria • 4step 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 • QRSwidth > 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
- 84. Akhtar Criteria • AVDissociation • 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
- 85. Griffith Criteria • SVTdiagnosed 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
- 86. What Makes ItEasy?
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- 88. New Algorithm • Usesa SINGLE EKG lead
- 89. VT vs SVTLead aVr (Verecki et al, January 2008, Heart Rhythm, 5/1)
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- 94. What Else isaVr Helpful For?
- 95. Pericarditis • Diffuse “global”STE or STD • PR segment depression inferior leads • PR segment elevation aVr
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- 101. Na+ Channel BlockerToxicity • 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
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- 110. TCA OD andWhat Else??
- 111. TCA “SALT” • Shock •AMS • Long QRS & QTc • Terminal R in Lead aVr • “SALT” is also the cure NaHCO3
- 112. Lead aVr • Maybe VERY helpful in… – STEMI – SVT r/t WPW – VT vs SVT in WCT – Pericarditis – TCA OD
- 113. Handout • Thanks toMichelle 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.comDr. Mattu’s • ecg.bidmc.harvard.edu/maven Lots of EKG’s • hqmeded-ecg.blogspot.com Dr. Smith • ecgguru.com Free Downloads