title: The neglected lead on electrocardiogram: T wave inversion in lead aVL, nonspecific finding or a sign for left anterior descending artery lesion?
abstract: BACKGROUND
  The electrocardiogram (ECG) is the most important diagnostic tool for acute myocardial infarction (AMI). T wave inversion (TWI) in lead aVL has not been emphasized or well recognized.
  
  
  OBJECTIVE
  This study examined the relationship between the presence of TWI before the event and mid-segment left anterior descending (MLAD) artery lesion in patients with AMI.
  
  
  METHODS
  Retrospective charts of patients with acute coronary syndrome between the months of January 2009 and December 2011 were reviewed. All patients with MLAD lesion were identified and their ECG reviewed for TWI in lead aVL.
  
  
  RESULTS
  Coronary angiography was done on 431 patients. Of these, 125 (29%) had an MLAD lesion. One hundred and six patients (84.8%) had a lesion > 50% and 19 patients (15.2%) had a lesion < 50%. Of the 106 patients who had a MLAD lesion > 50%, 90 patients (84.9%) had TWI in lead aVL and one additional lead. Of the 19 patients who had an MLAD lesion < 50%, 8 patients (42.1%) had TWI in lead aVL and one additional lead. Isolated TWI in lead aVL had an overall sensitivity of 76.7% (95% confidence interval [CI] 0.65-0.86), a specificity of 71.4% (95% CI 0.45-0.88), a positive predictive value of 92%, a negative predictive value of 41.7%, a positive likelihood ratio of 2.7 (95% CI 1.16-6.22), and negative likelihood ratio of 0.32 (95% CI 0.19-0.58) for predicting a MLAD lesion of > 50% (p = 0.0011).
  
  
  CONCLUSIONS
  TWI in lead aVL might signify a mid-segment LAD lesion. Recognition of this finding and early appropriate referral to a cardiologist might be beneficial. Additional studies are needed to validate this finding.
authors.affiliation: Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York; Department of Emergency Medicine, Mount Sinai School of Medicine, Lutheran Medical Center, Brooklyn, New York; Department of Emergency Medicine, St. George's School of Medicine, St. George, Grenada, West Indies.
authors.forename: Getaw Worku
authors.initials: GW
authors.lastname: Hassen
authors.affiliation: Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York.
authors.forename: Ana
authors.initials: A
authors.lastname: Costea
authors.affiliation: Medgar Evers College, Brooklyn, New York.
authors.forename: Tennyson
authors.initials: T
authors.lastname: Smith
authors.affiliation: A.T. Still University, School of Osteopathic Medicine, Mesa, Arizona.
authors.forename: Claire
authors.initials: C
authors.lastname: Carrazco
authors.affiliation: Department of Internal Medicine, Mount Sinai School of Medicine, Lutheran Medical Center, Brooklyn, New York.
authors.forename: Hafiz
authors.initials: H
authors.lastname: Hussein
authors.affiliation: Department of Internal Medicine, Mount Sinai School of Medicine, Lutheran Medical Center, Brooklyn, New York.
authors.forename: Bahareh
authors.initials: B
authors.lastname: Soroori-Rad
authors.affiliation: Department of Emergency Medicine, Lutheran Medical Center, Brooklyn, New York.
authors.forename: Sonia
authors.initials: S
authors.lastname: Vaidian
authors.affiliation: Department of Internal Medicine, Mount Sinai School of Medicine, Elmhurst Hospital Center, Queens, New York.
authors.forename: Justin
authors.initials: J
authors.lastname: Seashore
authors.affiliation: Department of Internal Medicine, Mount Sinai School of Medicine, Lutheran Medical Center, Brooklyn, New York.
authors.forename: Edris
authors.initials: E
authors.lastname: Alderwish
authors.affiliation: Department of Internal Medicine, Harvard University School of Medicine, Mount Auburn Hospital, Cambridge, Massachusetts.
authors.forename: Wei
authors.initials: W
authors.lastname: Sun
authors.affiliation: A.T. Still University, School of Osteopathic Medicine, Mesa, Arizona.
authors.forename: Alice
authors.initials: A
authors.lastname: Chen
authors.affiliation: Department of Emergency Medicine, Mount Sinai School of Medicine, Lutheran Medical Center, Brooklyn, New York.
authors.forename: Bonnie
authors.initials: B
authors.lastname: Simmons
authors.affiliation: Department of Emergency Medicine, Mount Sinai School of Medicine, Lutheran Medical Center, Brooklyn, New York.
authors.forename: Shakeel
authors.initials: S
authors.lastname: Usmani
authors.affiliation: Department of Emergency Medicine, New York Medical College, Metropolitan Hospital Center, New York, New York.
authors.forename: Hossein
authors.initials: H
authors.lastname: Kalantari
authors.affiliation: Department of Internal Medicine, Division of Cardiology, Mount Sinai School of Medicine, Lutheran Medical Center, Brooklyn, New York.
authors.forename: George
authors.initials: G
authors.lastname: Fernaine
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications*; D000368:Aged; D003324:Coronary Artery Disease / Q000175:diagnosis*; D004562:Electrocardiography; D005260:Female; D006801:Humans; D016013:Likelihood Functions; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012680:Sensitivity and Specificity
keywords: ECG; T wave inversion in lead aVL; mid-segment LAD lesion