Lead aVL on electrocardiogram: emerging as important lead in early diagnosis of myocardial infarction?

Published:March 06, 2014DOI:


      Although a diagnosis of acute myocardial infarction (AMI) that mandates emergency reperfusion therapy requires ST-segment elevation greater than 1 mm in at least 2 contiguous leads, some of the early electrocardiogram (ECG) changes of AMI can be subtle. Any ST-segment depression or T-wave inversion in lead aVL may be implicated in left anterior descending artery lesion or early reciprocal changes of inferior wall myocardial infarction, particularly when the clinical context suggests ischemia. Early recognition of reciprocal changes and serial ECG help initiate early appropriate intervention. Heightened awareness of ST segment and T-wave changes in lead aVL is of paramount importance to quickly identifying life-threatening condition.
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        • Brady W.J.
        • Perron A.D.
        • Chan T.
        Electrocardiographic ST-segment elevation: correct identification of acute myocardial infarction (AMI) and non-AMI syndromes by emergency physicians.
        Acad Emerg Med. 2001; 8: 349-360
        • Brady W.J.
        • et al.
        Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment.
        Acad Emerg Med. 2001; 8: 961-967
        • Jayroe J.B.
        • et al.
        Differentiating ST elevation myocardial infarction and nonischemic causes of ST elevation by analyzing the presenting electrocardiogram.
        Am J Cardiol. 2009; 103: 301-306
        • Myers G.B.
        • Klein H.A.
        • Stofer B.E.
        Correlation of electrocardiographic and pathologic findings in anteroseptal infarction.
        Am Heart J. 1948; 36: 535-575
        • Birnbaum Y.
        • Sclarovsky S.
        • Mager A.
        • Strasberg B.
        • Rechavia E.
        ST segment depression in a VL: a sensitive marker for acute inferior myocardial infarction.
        Eur Heart J. 1993; 14: 4-7
        • Rashduni D.L.
        • Tannenbaum A.K.
        Utility of ST segment depression in lead AVL in the diagnosis of right ventricular infarction.
        N J Med. 2003; 100: 35-37
        • Kracoff O.H.
        • et al.
        Twelve-lead electrocardiogram recording during percutaneous transluminal coronary angioplasty. Analysis of reciprocal changes.
        J Electrocardiol. 1990; 23: 191-198
        • Kracoff O.H.
        • et al.
        Reciprocal changes as the presenting electrocardiographic manifestation of acute myocardial ischemia.
        Am J Cardiol. 1993; 71: 1359-1362
        • Akhras F.
        • Upward J.
        • Jackson G.
        Reciprocal change in ST segment in acute myocardial infarction: correlation with findings on exercise electrocardiography and coronary angiography.
        Br Med J (Clin Res Ed). 1985; 290: 1931-1934
      1. Bischof, JE. New strategy distinguishes inferior STEMI from pericarditis.

        • Brady W.J.
        • et al.
        Reciprocal ST segment depression: impact on the electrocardiographic diagnosis of ST segment elevation acute myocardial infarction.
        Am J Emerg Med. 2002; 20: 35-38
        • Goldberger A.L.
        • Erickson R.
        Subtle ECG sign of acute infarction: prominent reciprocal ST depression with minimal primary ST elevation.
        Pacing Clin Electrophysiol. 1981; 4: 709-712
      2. Hanna EB, Glancy DL. ST-segment depression and T-wave inversion: classification, differential diagnosis, and caveats. Cleve Clin J Med 78, 404–414.

        • Haraphongse M.
        • Tanomsup S.
        • Kappagoda C.T.
        • Rossall R.E.
        Significance of ST-segment depression in inferior leads in patients with acute anterior infarction.
        Clin Invest Med. 1984; 7: 143-148
        • Jennings K.
        • Reid D.S.
        • Julian D.G.
        “Reciprocal” depression of the ST segment in acute myocardial infarction.
        Br Med J (Clin Res Ed). 1983; 287: 634-637
        • Menown I.B.
        • Allen J.
        • Anderson J.M.
        • Adgey A.A.
        ST depression only on the initial 12-lead ECG: early diagnosis of acute myocardial infarction.
        Eur Heart J. 2001; 22: 218-227
        • Odemuyiwa O.
        • Peart I.
        • Albers C.
        • Hall R.
        Reciprocal ST depression in acute myocardial infarction.
        Br Heart J. 1985; 54: 479-483
        • Pollehn T.
        • Brady W.J.
        • Perron A.D.
        Electrocardiographic ST segment depression.
        Am J Emerg Med. 2001; 19: 303-309
        • Akhras F.
        • Upward J.
        • Keates J.
        • Jackson G.
        Early exercise testing and elective coronary artery bypass surgery after uncomplicated myocardial infarction. Effect on morbidity and mortality.
        Br Heart J. 1984; 52: 413-417
        • Ando H.
        • Yotsukura M.
        • Sakata K.
        • Yoshino H.
        • Ishikawa K.
        Prognosis following acute myocardial infarction in patients with ST-T abnormalities on electrocardiograms obtained before myocardial infarction.
        Clin Cardiol. 2001; 24: 107-113
        • Becker R.C.
        • Alpert J.S.
        Electrocardiographic ST segment depression in coronary heart disease.
        Am Heart J. 1988; 115: 862-868
        • Croft C.H.
        • et al.
        Clinical implications of anterior S-T segment depression in patients with acute inferior myocardial infarction.
        Am J Cardiol. 1982; 50: 428-436
        • Hayden G.E.
        • Brady W.J.
        • Perron A.D.
        • Somers M.P.
        • Mattu A.
        Electrocardiographic T-wave inversion: differential diagnosis in the chest pain patient.
        Am J Emerg Med. 2002; 20: 252-262
        • Hassen G.W.
        • et al.
        The neglected lead on electrocardiogram: T wave inversion in lead aVL, nonspecific finding or a sign for left anterior descending artery lesion?.
        J Emerg Med. 2013;
      3. Brady W.J. ST segment and T wave abnormalities not caused by acute coronary syndromes. Emerg Med Clin North Am 2006;24:91–111, [vi].

        • Rosenbaum M.B.
        • Blanco H.H.
        • Elizari M.V.
        • Lazzari J.O.
        • Davidenko J.M.
        Electrotonic modulation of the T wave and cardiac memory.
        Am J Cardiol. 1982; 50: 213-222
        • Surawicz B.
        The pathogenesis and clinical significance of primary T wave abnormalities. Advances in electrophysiology. Grune & Stratton, New York1972: 377
        • Walder L.A.
        • Spodick D.H.
        Global T wave inversion.
        J Am Coll Cardiol. 1991; 17: 1479-1485
        • Wagner G.S.
        • et al.
        AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part VI: acute ischemia/infarction: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee; Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology.
        J Am Coll Cardiol. 2009; 53: 1003-1011
        • Myers G.B.
        • Klein H.A.
        • Hiratzka T.
        Correlation of electrocardiographic and pathologic findings in anteroposterior infarction.
        Am Heart J. 1949; 37: 205-236
        • Myers G.B.
        • Klein H.A.
        • Hiratzka T.
        Correlation of electrocardiographic and pathologic findings in posterior infarction.
        Am Heart J. 1949; 38: 547-592
        • Myers G.B.
        • Klein H.A.
        • Stofer B.E.
        Correlation of electrocardiographic and pathologic findings in lateral infarction.
        Am Heart J. 1949; 37: 374-417
        • Schuster E.H.
        • Bulkley B.H.
        Ischemia at a distance after acute myocardial infarction: a cause of early postinfarction angina.
        Circulation. 1980; 62: 509-515
        • Bertrand M.E.
        • et al.
        The provocation of coronary arterial spasm in patients with recent transmural myocardial infarction.
        Eur Heart J. 1983; 4: 532-535
        • Dunn R.F.
        • Kelly D.T.
        • Sadick N.
        • Uren R.
        Multivessel coronary artery spasm.
        Circulation. 1979; 60: 451-455
        • Mirvis D.M.
        Physiologic bases for anterior ST segment depression in patients with acute inferior wall myocardial infarction.
        Am Heart J. 1988; 116: 1308-1322
        • Shah P.K.
        • et al.
        Noninvasive identification of a high risk subset of patients with acute inferior myocardial infarction.
        Am J Cardiol. 1980; 46: 915-921
        • Platia E.V.
        • Grunwald L.
        • Mellits E.D.
        • Humphries J.O.
        • Griffith L.S.
        Clinical and arteriographic variables predictive of survival in coronary artery disease.
        Am J Cardiol. 1980; 46: 543-552
        • Schuster E.H.
        • Griffith L.S.
        • Bulkley B.H.
        Preponderance of acute proximal left anterior descending coronary arterial lesions in fatal myocardial infarction: a clinicopathologic study.
        Am J Cardiol. 1981; 47: 1189-1196
        • Wasserburger R.H.
        • Corliss R.J.
        Prominent precordial T waves as an expression of coronary insufficiency.
        Am J Cardiol. 1965; 16: 195-205
        • Dressler W.
        • Roesler H.
        High T waves in the earliest stage of myocardial infarction.
        Am Heart J. 1947; 34: 627-645
        • Sagie A.
        • et al.
        Acute anterior wall myocardial infarction presenting with positive T waves and without ST segment shift. Electrocardiographic features and angiographic correlation.
        Chest. 1989; 95: 1211-1215
        • Glancy D.L.
        • Doghmi W.
        Use of indicative and reciprocal electrocardiographic changes to help localize the site of coronary occlusion.
        Proc (Bayl Univ Med Cent). 2001; 14: 104-105
        • Haraphongse M.
        • Tanomsup S.
        • Jugdutt B.I.
        Inferior ST segment depression during acute anterior myocardial infarction: clinical and angiographic correlations.
        J Am Coll Cardiol. 1984; 4: 467-476
        • Norell M.S.
        • Lyons J.P.
        • Gardener J.E.
        • Layton C.A.
        • Balcon R.
        Significance of “reciprocal” ST segment depression: left ventriculographic observations during left anterior descending coronary angioplasty.
        J Am Coll Cardiol. 1989; 13: 1270-1274
        • Parale G.P.
        • Kulkarni P.M.
        • Khade S.K.
        • Athawale S.
        • Vora A.
        Importance of reciprocal leads in acute myocardial infarction.
        J Assoc Physicians India. 2004; 52: 376-379
        • Sorensen J.T.
        • et al.
        Significance of T-wave amplitude and dynamics at the time of reperfusion in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention.
        J Electrocardiol. 2009; 42: 677-683
        • Tamura A.
        • Kataoka H.
        • Mikuriya Y.
        • Nasu M.
        Inferior ST segment depression as a useful marker for identifying proximal left anterior descending artery occlusion during acute anterior myocardial infarction.
        Eur Heart J. 1995; 16: 1795-1799
        • Farhan H.L.
        • Hassan K.S.
        • Al-Belushi A.
        • Sallam M.
        • Al-Zakwani I.
        Diagnostic value of electrocardiographic T wave inversion in lead aVL in diagnosing coronary artery disease in patients with chronic stable angina.
        OMJ. 2010; 25: 124-127
        • Turhan H.
        • et al.
        Diagnostic value of aVL derivation for right ventricular involvement in patients with acute inferior myocardial infarction.
        Ann Noninvasive Electrocardiol. 2003; 8: 185-188