REVIEW ARTICLE

Clinical Value of Lead aVR

Andrés Ricardo Pérez Riera, M.D.,∗ Celso Ferreira, M.D., Ph.D.,∗
Celso Ferreira Filho, M.D., Ph.D.,∗ Sergio Dubner, M.D., F.A.C.C.,†
Raimundo Barbosa Barros, M.D.,‡ Francisco Femenı́a, M.D.,§
and Adrian Baranchuk, M.D., F.A.C.C.,¶
From the ∗ ABC Faculty of Medicine (FMABC), Discipline of Cardiology, Foundation of ABC (FUABC),
Santo André, São Paulo, Brazil; †Cardiology Department, Maternidad Suizo Argentina, Buenos Aires,
Argentina; ‡Departamento de Cardiologia do Hospital de Messejana Dr. Carlos Alberto Studart Gomes;
§Unidad de Arritmias. Departamento de Cardiologı́a. Hospital Español de Mendoza. Argentina; ¶Cardiology
Department, Queen’s University, Kingston, Ontario, Canada

Lead aVR is the only lead in the surface ECG that does not face the “typically” relevant walls of the left
ventricle. Historically, its value has been neglected most likely due to its unusual configuration and
direction, which appeared to have little correlation with other more congruous and easily diagnostic
frontal leads. The isolation of the unipolar leads in the Standard surface ECG presentation may also
have played an important role. Even with this “unfair” neglect, we know nowadays that it is very
sensitive to locate obstructed epicardial coronary arteries.
Besides helping distinguishing the culprit lesion of an infarct, lead aVR also helps recognizing other
conditions that could be of clinical significance such as pericarditis, Brugada syndrome, fascicular
blocks of the right branch, ectopic left atrial rhythms, etc. The purpose of this review is to revise the
clinical value of lead aVR in the recognition of frequent and not so frequent clinical conditions.
Ann Noninvasive Electrocardiol 2011;16(3):295–302
aVR; unipolar limb lead; aVR sign

The conventional ECG has 12 leads. Each lead signal is too small to be useful when the negative
records electrical activity of the heart from differ- electrode is Wilson’s central terminal. Lead aVL is
ent perspective. Therefore, it correlates to different at −30◦ relative to the lead I axis; aVR is at −150◦
anatomical areas of the heart. and aVF is at +90◦ .
aVR, aVL, and aVF are augmented unipolar Lead aVR is an augmented unipolar limb lead
leads in the frontal plane, after their inventor in which the positive electrode is on the right arm.
Dr. Emanuel Goldberger (known collectively as the aVR offers no specific view of the left ventricle and
Goldberger’s leads). They are derived from the same this is why it is mostly an ignored lead. Nonethe-
three electrodes as leads I, II, and III with the ref- less, the P-QRS-ST-T in lead aVR is often character-
erence lead on the limb being sensed and discon- istic in various conditions. Recognizing those ECG
nected from the other two. Unipolar leads also have pattern changes can improve the accuracy of clini-
two poles, as a voltage is measured; however, the cal diagnosis.1–3
negative pole is a composite pole (Wilson’s cen-
tral terminal) made up of signals from lots of other ARM LEADS SWITCH AND
electrodes. In a 12-lead ECG, all leads besides the
DEXTROCARDIA
limb leads are unipolar (aVR, aVL, aVF, V 1 , V 2 , V 3 ,
V 4 , V 5 , and V 6 ). The augmented limb leads aVR, In sinus rhythm, the sequence of depolarization
aVL, and aVF are amplified in this way because the is directed inferiorly and toward the left. Thus

Address for correspondence: Andrés Ricardo Pérez Riera, M.D.,Rua Sebastião Afonso, 885, CEP: 04417–100 Jardim Miriam, São Paulo,
Brazil. Fax: (55 11) 5625-7278/5506-0398; E-mail: riera@uol.com.br


C 2011, Wiley Periodicals, Inc.

295
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the P-wave polarity is always negative in lead tor is directed to right and upward, pointing to lead
aVR, positive in II, I, and aVF, and variable in III aVR.9,10 ST-segment depression in leads I, II, and
and aVL. V 4 through V 6 , in association with ST-segment ele-
Right and left arm leads reversal is the most vation in lead aVR identifies patients with three-
common mistake seen in ECG acquisition. If the vessel or LMCA critical occlusion (Fig. 2, Panel
P-QRS-T were upside down in lead I, a positive A)11,12
P wave in lead aVR (the true lead aVR is seen in Proper assessment of lead aVR in patients with
aVL) strongly suggests that right and left arm leads ACS may help identifying proximal left anterior de-
are switched.4–7 A normal R-wave progression in scending artery (LAD) occlusion or LMCA. Addi-
the horizontal plane rules out dextrocardia.8 Oth- tional analysis of lead V 1 does not improve diag-
erwise, dextrocardia is the most likely diagnosis nostic accuracy.13
if the arm leads were correctly placed. ECG man- ST-segment elevation in lead aVR in the presence
ifestations of dextrocardia are characterized by a of an anterior ST-segment elevation myocardial in-
reverse progression of R-wave voltage in the pre- farction (STEMI) suggests LAD occlusion proximal
cordial leads from V 2 to V 5 with predominant neg- to the first septal perforator branch (S1).
ative QRS complexes in all precordial leads.2,7,8 ST-segment elevation in lead aVR with simulta-
(Fig. 1) neous ST-segment depression in V 5 (VR-E + V 5 -D)
is a marker of ischemia due to severe LAD stenosis
in patients with single-vessel disease.12
ACUTE CORONARY SYNDROME ST-segment elevation in lead aVR and depres-
(ACS) sion in V 5 but without ST-segment elevation in V 1
strongly correlates with significant LAD and right
ST-segment elevation in lead aVR and ST- coronary artery (RCA) stenosis, a sign of double-
segment depression in the anterior and lateral leads vessel disease.10–14
suggests acute critical occlusion of the left main Elevation of the ST-segment in aVR in the set-
coronary artery (LMCA) because the ST injury vec- ting of ACS identifies patients with severe coronary

Figure 1. True dextrocardia: mirror image. Total atriovisceral situs inversus. ECG diagnosis: SAP to the right and below,
pointing at around +1200 . Negative P wave in leads I and aVL, positive in lead III. Reverse progression of R wave in
precordial leads V 2 to V 5 .
 A.N.E. r July 2011 r Vol. 16, No. 3 r Riera, et al. r Clinical Value of Lead aVR r 297

Figure 2. Panel A: A 12-lead ECG of a patient with ACS by total occlu-

sion of the left main coronary artery. Note ST-segment elevation in lead
aVR and widespread ST-segment depression involving the anterolateral pre-
cordial leads from V 4 to V 6 and the inferior limb leads (mirror image).
Panel B: A12-lead ECG of a patient with acute pericarditis. Note ST-segment
depression in leads aVR and V1 and ST-segment concave elevation in most of
the other leads.

artery disease. aVR ST-segment elevation with less In the posterior (from the “old” infarct classifi-
ST-segment elevation in lead V 1 is an important cation) and combined anterior + posterior myocar-
predictor of acute LMCA obstruction.10–14 dial infarction, the amplitude of the initial R wave
ST-segment depression in lead aVR is common in lead aVR is increased (>1.0 mm).17
in patients with acute inferior myocardial infarc-
tion related to the left circumflex artery (LCx).14–15
AORTIC DISSECTION
ST-segment depression ≥0.1 mV in lead aVR, dur-
ing an acute inferior myocardial infarction, pre- Lead aVR may contribute to the diagnosis of this
sented a sensitivity and specificity of 70% and ominous entity. In acute aortic dissection Stanford
94.3% for differentiating the culprit vessel lesion type A (or DeBakey I or II) when the proximal as-
(LCx vs RCA).15 cending aorta is involved, ST-segment elevation in
ST-segment depression in lead aVR during an lead aVR was reported.2,3,18 The physiopathologic
inferior STEMI predicts LCx infarction or larger mechanism to explain this observation was the ob-
RCA infarction involving a large posterolateral struction of the LMCA coronary ostium by the flap
branch.16 of the dissected aorta.
298 r A.N.E. r July 2011 r Vol. 16, No. 3 r Riera, et al. r Clinical Value of Lead aVR

Atrial Ectopic Rhythm et al.25 have recorded 12-lead ECGs in 154 adult
patients referred for electrophysiology study and
A positive P wave in lead aVR indicates an ec- radiofrequency ablation, during sinus rhythm and
topic right atrial rhythm. As such, P wave in lead narrow QRS complex tachycardia. One of the three
aVL is also positive. criteria that were found to be useful discrimina-
In focal right atrial tachycardia the P-wave con- tors of the tachycardia mechanism involved the
figuration in lead aVR can easily differentiate the aVR lead: ST-segment elevation in lead aVR pre-
site of origin. Right atrial tachycardia arising from dicted AVRT in 83% of the cases (sensitivity 71%;
the crista terminalis can be differentiated from the specificity 83%).25
tricuspid annulus and the septum away from the
tricuspid annulus by analyzing the P-wave config-
uration in lead aVR. A negative P wave in lead aVR DIAGNOSIS OF “RIGHT
identified crista terminalis atrial tachycardia with a VENTRICULAR END CONDUCTION
sensitivity of 100% and a specificity of 93%.19 Right DELAY” (RECD)
atrial tachycardia arising from the appendage can
Prominent final R wave in lead aVR is character-
also demonstrate negative P wave in lead aVR.20
istic of RECD, and useful criteria to differentiate it
from left anterior fascicular block (LAFB).26 There
Acute Pericarditis
is no anatomical confirmation that the right bun-
During the initial phase of pericarditis dle is divided in three branches as the left bundle
(<6 weeks); ST-segment elevation (<5 mm) is, however; the isolated block of one of the three
with superior concavity is frequently seen on contingent or right branch divisions inside the right
12-lead ECG. ventricle free wall, is generically called RECD.27
ST-segment changes can be subtle and usually Electro-vector-cardiographic (ECG/VCG) diagno-
present in several leads simultaneously, excluding sis of RECD remains somehow speculative.27 The
V 1 . PR-segment elevation in lead aVR is a hallmark only constant element is the presence of the final
of acute pericarditis.2,3,21 right end conduction delay, located in the supe-
Occasionally, ST-segment depression can be rior, middle, or inferior portions of the QRS loop in
observed in leads aVR, V 1 , as well as in the right the frontal plane, which could be the consequence,
accessory precordial leads (V 3 R, V 4 R, and V 5 R) as or not, of a dromotropic disorder (Fig.4, Panels A
part of a reciprocal phenomena.22 (Fig. 2, Panel B) and B).
In most cases, RECD corresponds to a normal
ACUTE TCA INTOXICATION variant and its clinical interest lies in the fact
that it causes ECG/VCG patterns that are easily
Clinical and electrocardiographic manifestations confused with LAFB and left posterior fascicular
of TCA overdose are well known and previously block. Additionally, it may mimic morphologies
described2,3,23,24 : ECG changes in lead aVR may that resemble electrically inactive areas both in
help in recognizing this clinical condition. In- the anterior and the inferior walls, the ECG/VCG
creased R-wave voltage and R/s ratio in lead aVR, of the Brugada Syndrome (BrS), and some con-
also reported as prominent R wave in lead aVR, are cealed forms of Arrhytmogenic Right Ventricular
maybe the most frequently observed ECG changes Cardiomyopathy/Dysplasia.28
in patients with TCA intoxication.24 (Fig. 3)
BRUGADA SYNDROME
DIFFERENTIAL DIAGNOSIS
BETWEEN TYPICAL Prominent final R wave in lead aVR (≥3 mm),
ATRIOVENTRICULAR NODE also known as the aVR sign, it was described as
REENTRANT TACHYCARDIA a possible risk marker of arrhythmic event when
(AVNRT) AND AV RECIPROCATING associated with a spontaneous Type 1 ECG Brugada
TACHYCARDIA (AVRT) pattern.2,3,28,29 (Fig. 5)
In the vectorcardiogram, RECD can be located
A simple algorithm in patients with regular nar- in the right superior quadrant of the frontal plane,
row complex tachycardia using a single-lead aVR corresponding to the territory of the superior or
allows distinguishing AVNRT from AVRT. Zhong subpulmonary fascicle of the right branch (right
 A.N.E. r July 2011 r Vol. 16, No. 3 r Riera, et al. r Clinical Value of Lead aVR r 299

Figure 3. ECG changes associated with acute TCA intoxication.

Figure 4. Panel A: Possible anatomical distribution of the three hypothetical fascicles (contingents) of the right branch
of the His bundle inside the right ventricle free wall. Panel B: Vectorcardiogram of a right end conduction delay located
in the superior, middle, and inferior portions of the frontal plane, respectively.

ventricular outflow tract [RVOT] between −100◦ aVR ≤1; have been found as right ventricular over-
and 160◦ ). The location of this delay explains the loading criteria.30,31
recording of prominent R wave in lead aVR. Larger
studies are needed to confirm the value of this sign
DIFFERENTIAL DIAGNOSIS OF
as a risk marker in BrS.
WIDE QRS COMPLEX
TACHYCARDIAS
Right Ventricular Overloading
Vereckei et al32 blindly analyzed 483 wide
Lead aVR faces the basal, infundibular, RVOT, QRS complex tachycardias of which 351 were
or crista supraventricularis regions. An R wave in ventricular tachycardia (VT), 112 supraventricular
lead aVR >5 mm (RVOT) and a Q/R ratio in lead tachycardias (SVT), and 20 preexcited tachycardias.
300 r A.N.E. r July 2011 r Vol. 16, No. 3 r Riera, et al. r Clinical Value of Lead aVR

Figure 5. Type 1 ECG Brugada pattern (“coved type”) with superior right end
conduction delay (RECD) and positive “aVR sign”: final R wave of aVR ≥3 mm.
RECD in frontal plane in a patient with BrS. ECG/VCG correlation (lower panel).

The authors used a novel single-lead aVR algorithm terminal (v[t]) 40 ms of the QRS complex. If
following four successive steps: yes; VT.

(1) First step: Presence of an initial R wave in lead If any of criteria 1 to 3 were present, VT diagnosis
aVR? If yes; VT. could be established. The aVR algorithm presented
(2) Second step: Presence of any initial R or Q greater sensitivity and negative predictive value
wave >40 ms? If yes; VT. for diagnosing VT when compared to the classic
(3) Third step: Presence of a notch or the de- Brugada criteria.
scending limb of a negative onset and predom-
inantly negative QRS? If yes; VT (notching on The Value of Reversed Lead aVR (−aVR)
the initial downstroke of a predominantly neg-
ative QRS complex). Case and Moss33 have recently proposed some
(4) Fourth step: Ventricular activation-velocity ra- modifications to the current frontal plane ECG
tio (v[i]/v[t]) ≤1 the vertical excursion (in mil- leads. One of them is a 180◦ degree alteration in
livolts) recorded during the initial (v[i]) and the configuration of lead aVR (to −aVR) to make
 A.N.E. r July 2011 r Vol. 16, No. 3 r Riera, et al. r Clinical Value of Lead aVR r 301

it more “accessible” to common understanding. 5. Baranchuk A, Shaw C, Alanazi H, et al. ECG pitfalls and arti-
The new reversed lead aVR (−aVR) will now be facts: The 10 commandments. Crit Care Nurse 2008;29:67–
73.
presented at +30◦ between the traditional Lead I 6. Baranchuk A. Right arm-left arm reversal. In Baranchuk A
(at 0◦ ) and Lead II (at + 60◦ ). This simple alteration (ed.): Atlas of Advanced ECG Interpretation. London, UK,
of the recording will simplify the recognition of pat- Remedica, 2011 (in press).
7. Rudiger A, Hellermann JP, Mukherjee R, et al. Electrocar-
terns that can affect this lead, as recognized by this diographic artifacts due to electrode misplacement and their
manuscript and others.2,3,33 The analysis of the ST frequency in different clinical settings. Am J Emerg Med
segment and the T wave in −aVR will be simpler 2007;25:174–178.
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The authors do not report any conflict of interest left main coronary artery obstruction by 12-lead electro-
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AVRT: AV Reentrant Tachycardia
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ECG: Electrocardiogram 16. Kanei Y, Sharma J, Diwan R, et al. ST-segment depression in
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LAFB: Left Anterior Fascicular Block inferior wall ST-segment elevation myocardial infarction.
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RECD: Right Ventricular End Conduction Delay
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