A Patient ECG Case: ST Elevation in aVR - What Does This Mean?

A 44-year-old male on hemodialysis with type 2 diabetes presents with chest pain. He has been recently seen for severe hypertension due to missed hemodialysis. He has no past coronary disease, though had pericarditis in the past. His ECG was as follows:

There is sinus rhythm, wide spread ST depression in multiple leads and 2 mm ST elevation in lead aVR, with 0.5 1 mm ST elevation in leads V1 and V2.

There was a previous ECG from 2 months ago:

Does this patient have a STEMI?

The patient was taken directly to the Cath Lab, however, his coronary angiogram only showed moderate LAD and RCA disease without any thrombotic obstruction. It was concluded the ECG abnormalities might have been related to uremic pericarditis and/or myocarditis. His chest pain resolved, and ST abnormalities improved after he was dialyzed, and he was discharged a few days later.

ST elevation in lead aVR (STEaVR) is less commonly discussed than ST elevation in other leads.

Here is what you should consider when you see STEaVR:

Global Ischemia: STEaVR can be a sign of left main coronary artery obstruction or severe multi-vessel coronary artery disease. This is a critical situation because the left main coronary artery supplies a large portion of the heart muscle.

Proximal LAD Occlusion: STEaVR may suggest a proximal occlusion of the left anterior descending artery (LAD).

Right Ventricular (RV) Involvement: In the context of an inferior myocardial infarction (ST elevation in leads II, III, and aVF), STEaVR may indicate RV involvement.

Non-ACS Causes: STEaVR is not a specific finding. It can be seen post cardiac arrest in the absence of ACS or in pericarditis. STEaVR has been reported often to be present without thrombotic coronary occlusion.

For whatever underlying cause, STEaVR is associated with high all cause hospital mortality. STEaVR warrants further diagnostic evaluation and urgent management. STEaVR should be evaluated within the context of the patient's symptoms, history and the entirety of the ECG findings.