Raymond Pranata1, Emir Yonas2, Veresa Chintya3 Vito Anggarino Damay1,4
1Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Banten, Indonesia
2Faculty of Medicine, YARSI University, Jakarta, Indonesia
3Sanjiwani General Hospital, Gianyar, Bali, Indonesia
4Department of Cardiology and Vascular Medicine, Siloam Hospital Lippo Village, Tangerang, Banten, Indonesia
ABSTRACT
Background: Lead aVR is frequently neglected in routine clinical practice. Usually, basal septum
receives blood supply from very proximal septal branches of the left anterior descending artery.
Transmural infarction of this area usually causes lead ST segment elevation in lead aVR signaling
proximal left coronary artery (proximal LAD or left main) occlusion. Ischemia and infarction
leads to metabolic and electrophysiological changes that may cause silent and symptomatic lifethreatening
arrhythmia.
Case Report: We reported 50 years old male patient presented to the ED 15 minutes since the
onset of severe pain in the abdomen accompanied by nausea and sweating. With ECG of diffuse
ST-segment depression with STE-aVR. The patient was then diagnosed with NSTE-ACS with
probable left main coronary artery (LMCA) obstruction with differential diagnosis of cholecystitis/
cholelithiasis with accompanying stable coronary artery disease. Patient felt better and rejected
hospitalization. The patient then came 7 hours later with dyspnea and worsening abdominal pain.
ECG of PSVT 189x/minute. Troponin was >10 ng/mL. Patient refused cardioversion and adenosine/
ATP was unavailable. Amiodarone 150 mg over 10 minutes was administered. After consideration,
patient was then referred to coronary angiography capable center for immediate invasive strategy.
Conclusion: ST elevation in lead aVR may signal a severe proximal left coronary artery disease
(LMCA or proximal LAD). Regardless whether it is caused by proximal left coronary artery disease
or not, it is also an independent predictor of mortality.
Keywords: supraventricular tachycardia, ST elevation aVR, left main coronary obstruction
