ST elevation in lead aVR – a marker of critical left main coronary artery stenosis
TL;DR
ST in aVR with diffuse ST depression represents a high-risk ECG pattern that should prompt urgent invasive evaluation and it is important to recognize that this ECG pattern can occur in other conditions, including severe anemia, shock states, and aortic dissection.
Abstract
Rationale: Lead augmented vector right (aVR) has historically been overlooked in acute coronary syndromes. ST-segment elevation (STE) in lead aVR with diffuse ST depression in multiple leads has emerged as a critical marker for left main coronary artery (LMCA) stenosis and triple-vessel disease (3VD). Recognition of this high-risk electrocardiogram (ECG) pattern is essential for timely diagnosis and improved outcomes. Patient concerns: In this retrospective case series, 5 consecutive patients presented to the emergency department between January 2023 and June 2024 with acute chest pain or cardiac arrest. Diagnoses: All 5 patients exhibited ECG findings of STE in aVR (≥1 mm) with diffuse ST depressions (≥1 mm) in ≥6 leads. All underwent coronary angiography within 24 hours, which confirmed LMCA stenosis (70%–99%; mean STE in aVR: 3.0 mm). A narrative literature review was performed using PubMed/MEDLINE databases (2000–2024) with search terms including “lead aVR,” “ST-segment elevation,” “left main coronary artery,” and “acute coronary syndrome.” Literature review shows that STE ≥0.5 mm in aVR with diffuse ST depression has been reported to have a sensitivity of 78% and specificity of 86% for LMCA/triple-vessel disease in prior studies. However, it is important to recognize that this ECG pattern can occur in other conditions, including severe anemia, shock states, and aortic dissection. STE ≥1 mm increases diagnostic yield. Patients with this pattern have higher in-hospital mortality (8.6%–19.4% vs 1.3%) and increased heart failure and reinfarction. Interventions: A total of 2 patients underwent coronary artery bypass grafting, 2 underwent percutaneous coronary intervention, and 1 was managed medically. Outcomes: No in-hospital deaths occurred. Lessons: STE in aVR with diffuse ST depression represents a high-risk ECG pattern that should prompt urgent invasive evaluation. Recognition of this high-risk ECG pattern is essential for timely diagnosis of critical LMCA stenosis and improved outcomes. However, findings from this small case series require validation in larger prospective cohorts.