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An Unusual Cause of ST-Segment Elevation in Lead aVR

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To identify the key insights or developments described in this article
1 Credit CME

A patient in their 30s with no cardiac history was transferred to the emergency department with 5 hours of palpitations and chest distress accompanied by amaurosis and weakness. Four hours before, the patient was admitted to another hospital with a heart rate of 123 beats per minute; their blood pressure fell to 86/42 mm Hg. A 12-lead electrocardiogram (ECG) was recorded at that hospital and demonstrated a distinct ST-segment elevation in lead aVR and ST-segment depression in leads I, II, III, aVF, and V2 to V6 (Figure, A).

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Sinus of Valsalva aneurysm is a relatively rare disease accompanied by several severe complications, including rupture. Misdiagnosis often occurs in clinical practice because of its rarity and atypical clinical manifestation. In recent years, the characteristics of ECG changes with ST-segment elevation in lead aVR (some cases also with the ST-segment elevation in lead V1) and diffuse ST-segment depression in other leads have been observed in patients with acute SVA rupture, which have not been well recognized by physicians.36 Because the ECG and other clinical manifestations are similar, those patients often receive a misdiagnosis of acute myocardial infarction due to critical occlusion of the left main coronary artery or triple-vessel disease. Dual antiplatelet therapy and thrombolysis might be administered improperly before a definitive diagnosis is confirmed, which might delay the treatment and lead to adverse outcomes. Therefore, it is important to develop strategies for early identification of SVA rupture. The following clinical signs might provide some valuable clues: (1) young patient onset with no risk factors for coronary heart disease; (2) patients present with palpitation, chest distress, or syncope instead of severe chest pain as chief complaints; (3) continuous cardiac murmurs may be detected by physical examination; (4) cardiogenic shock occurs at an early stage with a slight increase in serum cardiac troponin levels. In patients with these clinical features, the possibility of an SVA rupture should be considered, and echocardiography or cardiac computed tomography angiography should be performed immediately to confirm the diagnosis.

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Article Information

Corresponding Author: Guanhua Su, MD, PhD, Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Ave, Wuhan 430022, Hubei Province, China (suguanhua@163.com).

Published Online: February 28, 2022. doi:10.1001/jamainternmed.2021.8532

Conflict of Interest Disclosures: None reported.

References
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