What is the diagnosis and treatment for a patient with ST elevation in leads aVR and V1, suggestive of acute coronary syndrome?

ST Elevation in aVR and V1: Left Main or Proximal LAD Occlusion

ST elevation in aVR combined with V1, particularly when accompanied by widespread ST depression in eight or more leads, strongly suggests left main coronary artery or proximal multivessel disease and warrants immediate coronary angiography regardless of troponin results. 1

Diagnostic Interpretation

The ECG pattern of ST elevation in aVR and V1 represents a critical finding that indicates:

• Left main or multivessel coronary obstruction, especially when ST depression >0.1 mV appears in eight or more surface leads 1
• Proximal left anterior descending (LAD) occlusion when ST elevation extends to leads I, aVL, V1-V4 with reciprocal ST depression in inferior leads (II, III, aVF) 1
• This pattern is particularly significant if the patient presents with hemodynamic compromise (hypotension, shock, pulmonary edema) 1

Key ECG Features to Assess

• Magnitude of ST elevation in aVR: The presence of any ST elevation in aVR with widespread ST depression should raise concern 1
• Number of leads with ST depression: Eight or more leads with ST depression significantly increases likelihood of left main disease 1
• Presence of ST elevation in V1: When combined with aVR elevation, this suggests extensive anterior/septal involvement from proximal LAD occlusion 1
• Reciprocal changes: ST depression in inferior leads (II, III, aVF) supports proximal LAD occlusion 1

Immediate Management Algorithm

Step 1: Recognize the Pattern and Activate Emergency Response

• Obtain 12-lead ECG within 10 minutes of first medical contact 2
• Identify ST elevation in aVR and V1 with widespread ST depression 1
• Activate catheterization laboratory immediately - do not wait for troponin results 1, 3
• Initiate continuous cardiac monitoring for arrhythmias 3

Step 2: Administer Antithrombotic Therapy

• Aspirin 150-300 mg (non-enteric coating) immediately 3
• P2Y12 inhibitor (prasugrel 60 mg or ticagrelor 180 mg preferred over clopidogrel for faster onset) 3
• Parenteral anticoagulation (unfractionated heparin or bivalirudin) 3
• Consider glycoprotein IIb/IIIa inhibitor given high-risk anatomy 4

Step 3: Prepare for Emergency Coronary Angiography

• Target door-to-balloon time <120 minutes, but given the high-risk pattern, aim for <60 minutes 3
• Assess hemodynamic status - if cardiogenic shock present, consider mechanical circulatory support 3
• Alert cardiac surgery team given possibility of left main disease requiring emergency CABG 3

Critical Clinical Pitfalls

Common Misinterpretation

Important caveat: Recent research found that ST elevation in aVR with multilead ST depression identified an acutely occluded coronary in only 10% of cases, and none were left main or proximal LAD occlusions 5. However, this pattern was associated with 31% in-hospital mortality, indicating severe disease requiring urgent (not necessarily emergent) catheterization 5.

Reconciling Contradictory Evidence

While guidelines strongly recommend treating ST elevation in aVR/V1 with widespread ST depression as a STEMI equivalent requiring immediate catheterization 1, 2, the research by Harhash et al. suggests this pattern may not always represent acute occlusion 5. The appropriate clinical approach is:

• Proceed with urgent coronary angiography (within 2 hours rather than immediate STEMI activation) given the 31% mortality and high prevalence of severe coronary disease (59%) 5
• Assess hemodynamic stability: If patient has cardiogenic shock, chest pain, or electrical instability, proceed with immediate catheterization 1, 3
• If hemodynamically stable: Urgent catheterization within 2-24 hours is appropriate, with continuous monitoring 1, 5

Other Diagnostic Considerations

• Tachycardia with this pattern may represent Type 2 MI from supply-demand mismatch rather than acute occlusion, but still requires urgent evaluation 6
• Obtain high-sensitivity troponin at presentation and 1-2 hours later to assess for myocardial necrosis 3
• Perform echocardiography to assess left ventricular function and exclude mechanical complications 3

Risk Stratification

This ECG pattern places patients in the highest risk category for adverse outcomes:

• 31% in-hospital mortality even when acute occlusion is not present 5
• 59% have severe multivessel coronary disease requiring revascularization 5
• High risk for cardiogenic shock and malignant arrhythmias 1
• May require emergency CABG if anatomy unfavorable for PCI 3

Hemodynamic Monitoring

• Continuous blood pressure monitoring 3
• Consider arterial line placement given high shock risk 3
• Assess for signs of cardiogenic shock: hypotension, altered mental status, cool extremities, oliguria 1
• Do not routinely use intra-aortic balloon pump unless mechanical complications present 3

Special Populations

Patients with Cardiac Arrest

• 36% of patients with this ECG pattern present with cardiac arrest 5
• Proceed directly to emergency catheterization after return of spontaneous circulation 5
• Consider mechanical circulatory support early 3

Patients with Prior CABG

• This pattern may represent acute vein graft occlusion 1
• Emergency angiography remains indicated 1