From the Guidelines
ST segment changes in lead aVR during a treadmill test should be interpreted with caution, considering the patient's overall clinical context, including symptoms and valve hemodynamics, as they may indicate severe aortic stenosis or coronary artery disease, and prompt further evaluation with more definitive testing. When evaluating patients with aortic valve disease, exercise testing, such as a treadmill test, can provide valuable information on physiological changes with exercise and symptom provocation 1. However, the interpretation of ST segment changes, particularly in lead aVR, must consider the patient's underlying condition, including the severity of aortic stenosis and the presence of coronary artery disease.
Key Considerations
- ST segment depression is common in patients with aortic stenosis during exercise and is nonspecific for coronary artery disease 1.
- An abnormal hemodynamic response, such as hypotension or failure to increase blood pressure with exercise, is a poor prognostic finding in patients with severe aortic stenosis 1.
- Exercise testing can identify a limited exercise capacity, abnormal blood pressure response, or arrhythmia, which are important considerations in the management of patients with valvular heart disease 1.
- The presence of symptoms, such as angina, dyspnea, dizziness, or syncope, during exercise testing should be considered indicative of symptomatic aortic stenosis, even if the clinical history is equivocal 1.
Clinical Implications
- Patients with asymptomatic aortic stenosis and an aortic velocity of 4.0 m/s or greater, or mean pressure gradient of 40 mmHg or higher, may undergo exercise testing to assess physiological changes with exercise and confirm the absence of symptoms 1.
- However, exercise testing should not be performed in symptomatic patients with aortic stenosis due to the high risk of complications, including syncope, ventricular tachycardia, and death 1.
- The interpretation of ST segment changes in lead aVR during a treadmill test should be integrated with other clinical and hemodynamic data to guide management decisions and determine the need for further testing or intervention.
From the Research
AVR Lead ST Segment Changes During Treadmill Test
- The diagnostic and prognostic value of ST-segment deviation in lead aVR during exercise testing has been assessed in patients suspected of having myocardial ischemia 2.
- Studies have shown that exercise-induced ST-segment elevation in lead aVR is a useful indicator of significant left main or ostial LAD coronary artery stenosis 3, 4.
- ST elevation in lead aVR during exercise testing indicates inducible myocardial ischemia independently of ST depressions in lead V5 and clinical factors, and also predicts major adverse cardiac events (MACE) during follow-up 2.
- The presence of ST-segment elevation in lead aVR during treadmill testing is associated with a higher likelihood of LAD stenosis and coronary artery disease 3, 4.
- However, it is essential to consider that the relationship between AS, AVR, and coronary hemodynamic status is complex, and decisions regarding coronary revascularization should be based on a comprehensive understanding of this relationship and a multidisciplinary team approach 5.
Key Findings
- ST-segment elevation in lead aVR during exercise testing is a significant predictor of LMCA or ostial LAD stenosis 3.
- The diagnostic accuracy of ST changes for myocardial ischemia is similar in leads aVR and V5 2.
- ST-segment depression in inferior leads during treadmill exercise testing can be related to significant coronary artery disease, although it is a less common finding 6.
Clinical Implications
- Exercise-induced ST-segment elevation in lead aVR should not be ignored and can provide valuable diagnostic information in patients with suspected myocardial ischemia 3.
- The assessment of CAD and the role of revascularization in patients with concomitant AS and CAD require a tailored approach, taking into account the complex relationship between these conditions 5.