What is the management approach for a patient with ST elevation in lead aVR (augmented voltage right) suggestive of acute myocardial infarction?

From the Guidelines

Management of a patient with ST elevation in lead aVR suggestive of acute myocardial infarction requires immediate intervention as it often indicates left main coronary artery or proximal left anterior descending artery occlusion, or severe triple-vessel disease. Initial management includes administering aspirin (325 mg chewed), antiplatelet therapy such as ticagrelor (180 mg loading dose) or clopidogrel (600 mg loading dose), and anticoagulation with unfractionated heparin (60-70 units/kg IV bolus, maximum 4000 units) 1. Urgent cardiac catheterization with potential percutaneous coronary intervention should be performed within 90 minutes of first medical contact. If PCI is not available within this timeframe, fibrinolytic therapy should be considered if there are no contraindications. Supportive measures include oxygen therapy to maintain saturation above 94%, IV access, continuous cardiac monitoring, pain management with morphine (2-4 mg IV), and nitrates (sublingual nitroglycerin 0.4 mg every 5 minutes for chest pain, unless contraindicated) 1. Beta-blockers like metoprolol (5 mg IV every 5 minutes, up to 15 mg) should be given if the patient is hemodynamically stable without signs of heart failure. ST elevation in aVR often indicates a worse prognosis due to the large area of myocardium at risk, so aggressive management and close monitoring for complications such as cardiogenic shock, arrhythmias, and mechanical complications are essential. Some key points to consider in the management of these patients include:

• The importance of prompt recognition and treatment of ST elevation in lead aVR as it is associated with high-risk coronary anatomy 1
• The use of cardiac catheterization and potential percutaneous coronary intervention as the preferred reperfusion strategy 1
• The role of supportive measures such as oxygen therapy, pain management, and beta-blockers in reducing morbidity and mortality. It is also important to note that the presence of ST-depression in eight or more surface leads, coupled with ST elevation in aVR, suggests ischemia due to multivessel or left main coronary artery obstruction, particularly if the patient presents with hemodynamic compromise 1. In hospitals or settings where coronary angiography is not immediately available, rapid confirmation of segmental wall-motion abnormalities by two-dimensional echocardiography may assist in making a decision for emergency transfer to a PCI center 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Management Approach for ST Elevation in Lead aVR

The management approach for a patient with ST elevation in lead aVR suggestive of acute myocardial infarction involves several key considerations:

• Early invasive approach: Studies such as 2 suggest that an early invasive approach might be especially beneficial in patients presenting with ST-segment elevation in lead aVR, as it is associated with more severe coronary artery disease.
• Antiplatelet and anticoagulation therapy: As recommended in 3, aspirin and a second antiplatelet agent, as well as parenteral anticoagulation, should be considered for patients with suspected acute coronary syndrome, unless contraindicated.
• Urgent catheterization: While routine STEMI activation for emergent revascularization may not be warranted, as found in 4, urgent catheterization appears to be important for patients with ST elevation in lead aVR and multilead ST depression.
• Systematic evaluation: A systematic approach to evaluating patients with ST-segment elevation in lead aVR, as proposed in 5, can help identify the underlying cause and guide management.

Key Considerations

• Severe coronary artery disease: ST-segment elevation in lead aVR is often associated with severe coronary artery disease, including left main or 3-vessel disease, as noted in 2 and 6.
• High-risk patients: Patients with ST elevation in lead aVR are at higher risk for adverse outcomes, including in-hospital death and recurrent ischemic events, as reported in 2 and 4.
• Individualized management: Management should be tailored to the individual patient, taking into account their specific clinical presentation, underlying coronary anatomy, and other factors, as emphasized in 5 and 3.