Right Precordial Leads and Lead aVR at Exercise Electrocardiography: Does It Change Test Results?

Background: A recent study on exercise testing (ET) suggested that ST‐segment changes in the right precordial leads (RPL) may increase its sensitivity substantially. However, this study looked at a highly selected population of patients who all underwent thallium‐201 scintigraphy and coronary angiography. The present study evaluated the clinical utility of ST‐segment changes in the RPL and lead aVR in an unselected population of patients undergoing ET. Methods: A total of 906 consecutive patients who received ET were included in the study. ET was done using the Bruce Protocol with a 12‐lead electrocardiogram (ECG) substituting V₄R and V₆R for V₁ and V₆. Leads V₁ and V₆ were selected for omission as these two leads hardly ever manifest changes in isolation. Substituting two leads would obviate the need for a more complex recording system, thus improving clinical utility. Results: On the basis of horizontal/downsloping ST‐segment depression (STD) of 1.0 mm or more (the usually accepted criterion for a positive ET), 159 (17.5%) patients had a positive ET. In those patients with a negative ET (545 patients), 4 patients (0.7%) manifested STD and 5 patients (0.9%) manifested ST‐segment elevation (STE) in leads V₄R and/or V₆R, respectively. Of note, 44.7% of the positive ET group had STE in lead aVR. Conclusion: The use of ST‐segment changes in RPL during exercise stress testing does not appreciably change the test results of a standard ET. If one was to consider an additional marker, STE in aVR may be more useful, as it shows a stronger correlation with positive tests and does not require the recording of additional leads.