Acute Left Main Coronary Artery Total Occlusion Without ST-Segment Elevation in Lead aVR

Author : R. Putra, M. Limbong, Y.S. Pratama, A. Mustika, Y. Herry
Upload Date : 19-04-2018

Background: Acute left main coronary artery (LMCA) total occlusion is a life-threatening condition which usually presents with ST-segment elevation (STE) in lead aVR accompanied by widespread ST-segment depression. We report a case of acute LMCA total occlusion presented with ST elevation in lead I and aVL, without ST elevation in lead aVR

Case Presentation: A 64-year-old male was admitted to our emergency department with chest heaviness lasting for 6 hours. He had history of hypertension, recurrent stroke and brain arteriovenous malformation. Electrocardiogram (ECG) on admission showed STE in lead I and aVL with ST depression in inferior leads, and precordial poor R wave progression (PRWP), but no aVR STE was observed. He was diagnosed with high lateral STEMI, then underwent urgent coronary angiography which revealed an acute ostial LMCA total occlusion without antegrade flow and a dominant right coronary artery (RCA). Primary PCI was performed with 3 drug eluting stents and eptifibatide administration, and successfully restored coronary flow to TIMI flow III

Discussion: Lead aVR STE in acute myocardial infarction has 93.1 – 99% negative predictive value to predict LMCA occlusion. aVR STE can be caused by ischemia in: (1) basal interventricular septum (IVS); (2) right ventricular outflow tract; and (3) lateral and precordial wall as a reciprocal image. In our patient, the absence of aVR STE, despite having a totally occluded LMCA, could be caused by a dominant RCA which covered the most of lateral wall circulation. In the absence of aVR STE, a suspicion of occlusion before the first branch of LAD should be considered when PRWP and STE in I and aVL are present

Conclusion: Acute LMCA total occlusion can occur without aVR STE, especially in a patient with a dominant RCA which covers the most of lateral wall circulation

KEYWORDS : aVR, left main coronary artery occlusion, electrocardiogram

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