Chest Pain and ST-Segment Elevation in Lead aVR

Here’s an interesting case submitted by Chris B.

You are dispatched to a 63 year old male complaining of chest pain.

On arrival you find the patient lying supine in bed, alert and oriented to person, place, time and event. His general appearance is poor. He is pale, but not diaphoretic. Skin temp is normal. His chest pain is substernal 6/10 and non-radiating.

Vital signs

  • RR: 12 non-labored
  • HR: 68
  • NIBP: 97/55
  • SpO2: 81% on room air

Breath sounds are clear bilaterally.

Past medical history

  • 4-vessel bypass approximately 6 years ago
  • End stage renal disease
  • Diabetes

The cardiac monitor is attached.

A 12 lead ECG is obtained.

How sick is this patient?

What do you think is going on?

*** UPDATE ***

This was the first case I ever posted that showed ST-segment elevation in leads aVR and V1 with widespread ST-segment depression.

A recent Twitter poll showed that 72% of the #FOAMed community reports that they considered this finding to be a STEMI equivalent (indicating left main coronary artery occlusion) complete with prehospital activation of the cardiac cath lab.

It is probably based on this article.

Rokos I, French W, Mattu A et al. Appropriate Cardiac Cath Lab activation: Optimizing electrocardiogram interpretation and clinical decision-making for acute ST-elevation myocardial infarction. American Heart Journal. 2010;160(6):995-1003.e8. doi:10.1016/j.ahj.2010.08.011.

However, this is controversial (even though I argued the same thing here).

Stephen Smith, M.D. (@SmithECGBlog) argues that ST-segment elevation in leads aVR and V1 with widespread ST-segment depression really represents subendocardial ischemia, which may represent left main coronary occlusion or proximal LAD occlusion, but it may also represent left main insufficiency, 3 vessel disease, demand ischemia, anemia, CO poisoning, aortic stenosis, or some other cause that requires further workup in the Emergency Department.

The bottom line

Make sure you have buy-in from Emergency Medicine and Cardiology before you start calling this from the field!

Further reading

Five primary patterns of ischemic ST-depression, with ST-elevation. Some are STEMI equivalents.

The difference between left main occlusion and left main insufficiency

Is this a STEMI equivalent?

The 12-Leads of Christmas: aVR


  • Tom, I don’t like the r wave progression, nor the depression in the precordials, and the eleveation in aVR is concerning alone with the reciprocal change in Lead II given the rest of the EKG and the signs/symptoms presenting. I would try obtaining a right sided EKG, possibly posterior as well. High flow oxygen, two lines due to presentation and a bolus to see if his skins improve based on his BP, concern lies on his history. Am I close??

  • Tom B says:

    You are close. This patient is very sick, and the story doesn't have a happy ending. I'm glad you noticed the ST segment elevation in lead aVR. Although it's not without controversy, many reliable sources suggest that ST segment elevation in lead aVR (with less ST segment elevation in lead V1) and ST segment depression in 6 or > leads is highly suggestive of either a proximal lesion in the left main coronary artery (LMCA) or severe 3-vessel disease. With this patient's history of CABGx4 approximately 6 years ago, it could be either or both! Regrettably, this patient went into pulseless VT shortly after arrival in the ED and was not successfully resuscitated.

  • walma says:

    Electrocardiographic Prediction of Acute Left Main Coronary Artery OcclusionRostoff P, Piwowarska W, Gackowski A, et al. Amer J Emerg Med 2007;25:852-855. This isn’t new news to anyone that’s been attending advanced ECG workshops (e.g. FHC!) or keeping up with some of the ECG literature, but just one more publication on the utility of lead aVR, the lead I refer to as the ‘forgotten 12th lead’ or the ‘Rodney Dangerfield lead.’ The authors wrote this brief report in response to an article we published in November 2006 pertaining to lead aVR.1 In that article, we discussed that ST-segment elevation (STE) in lead aVR in patients with acute cardiac ischemia has been found to be highly specific for acute occlusion of the left main coronary artery (LMCA). Why should we worry more about ACS with LMCA involvement vs. any other ACS case? Very simple…the literature indicates that when a patient has ACS involving the LMCA, they carry a 70% risk of developing cardiogenic shock or dying, and the only treatment that has been demonstrated to improve outcomes in patients with LMCA occlusion is rapid PCI (or often they will need CABG). No medical therapies have been found to reliably improve the prognosis, including thrombolytics. This is not just applicable to patients with STEMI, it also applies if the patient has an ST-depression ACS. The authors performed an analysis of published data and report that STE in lead aVR during ACS is 77.6% sensitive, 82.6% specific, and 81.5% accurate for LMCA occlusion. These authors don’t specifically comment on what degree of STE is required (0.5 mm? 1.0 mm?), but in our evaluation of the literature there are three patterns that appear to predict LMCA occlusion: (1) STE in lead aVR which is greater in magnitude than the STE in lead V1; (2) STE in lead aVR with simultaneous STE in lead aVL; or (3) STE in lead aVR > 1.5 mm. Also, it is important to bear in mind that these findings only apply when there is evidence of ischemia or infarction in other leads as well, so this is really not applicable to non-ACS patients. For example, some patients with SVT will develop STE in lead aVR, and this is not clinically predictive of LMCA disease. For anyone wondering why STE occurs in lead aVR, apparently it’s not completely clear. The authors cite one theory that it is caused by transmural ischemia of the basal part of the interventricular septum, where the injury’s current is directed toward the right shoulder thus producing STE in lead aVR. Sounds good to me. The bottom line is this: when a patient has evidence of ischemia or infarction on the ECG, take a special look at lead aVR. If there is STE there, the first thing you need to do is to get on the phone and find a cardiologist that will take the patient for PCI. And if you have to transfer the patient and have a choice of where to send the patient, opt for a center that also has cardiac surgeons available for CABG. They will often be needed. 1. Williamson K, Mattu A, Plautz CU, et al. Electrocardiographic applications of lead aVR. Am J Emerg Med 2006;24:864-874.

  • Tom B says:

    You’re just a wealth of information! Thanks again, Maciek! Tom

  • SoCal Medic says:

    Interesting literature, thanks..

  • Dr Zeeshan Ahmad says:

    good stuff walma,,very informative,,but he is a pt of End stage renal disease and nobody talked about his Electrolyte Status,,i suspect Potassium imbalance(hyperkalemia) as he has history of Cabg x 4,,surely there might be an ongoing Cardiac ischemia

  • chris t says:

    Man everytime I read one of this sites post and replys I learn so much. Thankyou for taking the time to type, suggest, teach and be taught. I wanna be that good !

  • Hassan says:

    i hate medicine

  • Dodge says:

    As always a very imformative case presentation coming from a service that dose not utilise pre-hospital 12 lead this site as proved a wealth of information so keep up the good work

  • amk-emtb says:

    Thank you for taking time to share what you have researched and learned. I am a E.M.T-B, and have been taught that a good Medic was/is a informed and Great Basic. I am looking to go to school with in the next year to be a medic. There for love reading and doing my own research in the medical feild/EMS. I am very lucky and have a very good mentor that I talk to and he is a very well informed Medic, which is how I have come across this sit. I full understand that doing my own research and reading will not take the place of Medic school, but I hope by doing this I will have a better understanding of what I am learning.

  • Dr.Hafez Al-Ali says:

    this pt have serious attack ,acceralated ischemic crisis most ofTen NSTEMI and because of st elevation of AVR, means triple vessel disease or LM LESION , TO MANGE pt we need URGENT PCI.

  • Cool case, and awesome comments!  More pearls for aVR.

  • hans duiven says:

    The diagnose is probably one of these two:
    -Three Vessel disease
    -Acute LMCA occlusion

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