Can a patient with type 2 myocardial infarction (MI) present with atrioventricular septal (AVR) ST elevation?

Can Type 2 MI Present with aVR ST Elevation?

Yes, patients with type 2 myocardial infarction can present with aVR ST elevation, though this ECG pattern typically indicates severe multivessel ischemia or left main coronary artery obstruction rather than being a defining feature of type 2 MI. 1

Understanding the ECG Pattern in Type 2 MI

Type 2 MI is defined by myocardial oxygen supply-demand mismatch from non-atherothrombotic causes (such as severe anemia, tachyarrhythmias, hypotension, or sepsis), and requires elevated cardiac troponin with objective evidence of ischemia including new or presumed new ischemic ECG changes. 2 These ECG changes can include:

• ST-segment depression 2
• T-wave inversion 2
• Transient ST elevation 2
• ST elevation in lead aVR with widespread ST depression 1

The Specific aVR Pattern and Its Significance

The European Society of Cardiology guidelines specifically identify ST elevation in aVR coupled with ST depression >0.1 mV in eight or more surface leads as an atypical ECG presentation that deserves prompt management in patients with signs and symptoms of ongoing myocardial ischemia. 1 This pattern suggests:

• Multivessel coronary artery disease or left main coronary artery obstruction 1
• Particularly concerning when the patient presents with hemodynamic compromise 1
• Represents severe global ischemia rather than a single vessel occlusion 1

Critical Clinical Context

The key distinction is that type 2 MI occurs when a precipitating stressor (anemia, sepsis, tachyarrhythmia, hypotension) creates the supply-demand mismatch, NOT from acute coronary plaque rupture. 2 However, patients with underlying severe coronary disease (including left main or multivessel disease) are particularly vulnerable to developing type 2 MI when exposed to these stressors. 3, 2

For example:

• A patient with severe anemia and underlying left main disease may develop type 2 MI with aVR ST elevation because the anemia creates insufficient oxygen delivery to already compromised myocardium 3, 2
• A patient with septic shock and multivessel disease may show this ECG pattern as global hypoperfusion worsens pre-existing coronary stenoses 2

Diagnostic Algorithm for This Scenario

When you encounter aVR ST elevation with widespread ST depression:

1. Identify the precipitating condition: Look for severe anemia, tachyarrhythmias, bradyarrhythmias, hypotension/shock, respiratory failure, severe hypertension, or sepsis 2

2. Confirm troponin elevation: High-sensitivity troponin above 99th percentile with rising and/or falling pattern 2

3. Determine if acute coronary thrombosis is present: This requires urgent coronary angiography 1, 2

   • If acute plaque rupture/thrombosis is found = Type 1 MI
   • If severe coronary disease without acute thrombosis + clear precipitating stressor = Type 2 MI

4. Assess hemodynamic status: The aVR pattern with hemodynamic compromise mandates emergency angiography regardless of MI type 1

Critical Management Pitfall

Do NOT automatically initiate aggressive antiplatelet and anticoagulation therapy based solely on the aVR ST elevation pattern if type 2 MI is suspected, especially if the precipitating cause is severe bleeding or anemia. 2 The European Society of Cardiology and American College of Cardiology emphasize that antiplatelet therapy and aggressive anticoagulation are often inappropriate and may be contraindicated in type 2 MI. 2

Instead:

• Correct the underlying precipitating condition (transfuse for anemia, control arrhythmia, treat sepsis, optimize hemodynamics) 2
• Proceed with urgent angiography to define coronary anatomy and guide revascularization decisions 1
• Reserve antiplatelet/anticoagulation decisions until the MI type is definitively established 2

Prognosis Considerations

Patients with type 2 MI have multiple comorbidities and similar or higher mortality compared to type 1 MI, with causes of death often being non-cardiovascular. 4, 5, 6 The presence of aVR ST elevation with widespread ST depression indicates severe underlying coronary disease, which compounds the risk when combined with the precipitating stressor. 1