{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T19:50:03Z","timestamp":1791575403589,"version":"4.3.4"},"reference-count":20,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"41","license":[{"start":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T00:00:00Z","timestamp":1791504000000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,10,9]]},"abstract":"<jats:sec>\n                    <jats:title>Rationale:<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Patient concerns:<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Diagnoses:<\/jats:title>\n                    <jats:p>All 5 patients exhibited ECG findings of STE in aVR (\u22651\u2009mm) with diffuse ST depressions (\u22651\u2009mm) in \u22656 leads. All underwent coronary angiography within 24 hours, which confirmed LMCA stenosis (70%\u201399%; mean STE in aVR: 3.0\u2009mm). A narrative literature review was performed using PubMed\/MEDLINE databases (2000\u20132024) with search terms including \u201clead aVR,\u201d \u201cST-segment elevation,\u201d \u201cleft main coronary artery,\u201d and \u201cacute coronary syndrome.\u201d Literature review shows that STE \u22650.5\u2009mm 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 \u22651\u2009mm increases diagnostic yield. Patients with this pattern have higher in-hospital mortality (8.6%\u201319.4% vs 1.3%) and increased heart failure and reinfarction.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interventions:<\/jats:title>\n                    <jats:p>A total of 2 patients underwent coronary artery bypass grafting, 2 underwent percutaneous coronary intervention, and 1 was managed medically.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Outcomes:<\/jats:title>\n                    <jats:p>No in-hospital deaths occurred.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Lessons:<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1097\/md.0000000000051001","type":"journal-article","created":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T19:01:25Z","timestamp":1791572485000},"page":"e51001","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["ST elevation in lead aVR \u2013 a marker of critical left main coronary artery stenosis"],"prefix":"10.1097","volume":"105","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8831-3690","authenticated-orcid":false,"given":"May Thu","family":"Kyaw","sequence":"first","affiliation":[{"name":"University of Medicine 2, Yangon, Myanmar"},{"name":"Heart and Vascular, Victoria Hospital, Yangon, Myanmar."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"R1-20261009","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1016\/j.jelectrocard.2019.07.014","article-title":"Evolution of our understanding of the aVR sign.","volume":"56","author":"Gibbs","year":"2019","journal-title":"J Electrocardiol"},{"key":"R2-20261009","doi-asserted-by":"crossref","first-page":"e618","DOI":"10.1161\/CIR.0000000000000617","article-title":"Fourth universal definition of myocardial infarction (2018).","volume":"138","author":"Thygesen","year":"2018","journal-title":"Circulation"},{"key":"R3-20261009","doi-asserted-by":"crossref","first-page":"e250387","DOI":"10.1136\/bcr-2022-250387","article-title":"In defence of aVR: an NSTEMI that needed emergent reperfusion.","volume":"15","author":"Mesquita","year":"2022","journal-title":"BMJ Case Rep"},{"key":"R4-20261009","doi-asserted-by":"crossref","first-page":"302","DOI":"10.1186\/s40001-022-00931-5","article-title":"The prognostic effect of ST-elevation in lead aVR on coronary artery disease, and outcome in acute coronary syndrome patients: a systematic review and meta-analysis.","volume":"27","author":"Kazemi","year":"2022","journal-title":"Eur J Med Res"},{"key":"R5-20261009","doi-asserted-by":"crossref","first-page":"240","DOI":"10.1016\/j.jelectrocard.2012.12.016","article-title":"Diffuse ST depression with ST elevation in aVR: is this pattern specific for global ischemia due to left main coronary artery disease?","volume":"46","author":"Knotts","year":"2013","journal-title":"J Electrocardiol"},{"key":"R6-20261009","first-page":"13","article-title":"ST segment elevation in lead aVR as a predictor of left main coronary artery lesion in acute coronary syndrome.","volume":"11","author":"Manuel","year":"2005","journal-title":"Philipp Heart Cent J"},{"key":"R7-20261009","doi-asserted-by":"crossref","first-page":"1366","DOI":"10.1016\/j.amjcard.2005.01.085","article-title":"Predictors of left main or three-vessel disease in patients who have acute coronary syndromes with non-ST-segment elevation.","volume":"95","author":"Kosuge","year":"2005","journal-title":"Am J Cardiol"},{"key":"R8-20261009","doi-asserted-by":"crossref","first-page":"43","DOI":"10.55519\/JAMC-01-10590","article-title":"Diffuse ST depression with ST elevation aVR in acute coronary syndrome and its association with significant left main or three vessel coronary artery disease and its confounders.","volume":"35","author":"Ahmed","year":"2023","journal-title":"J Ayub Med Coll Abbottabad"},{"key":"R9-20261009","doi-asserted-by":"crossref","first-page":"1059","DOI":"10.1136\/hrt.2003.026799","article-title":"Electrocardiographic features in patients with acute myocardial infarction associated with left main coronary artery occlusion.","volume":"90","author":"Kurisu","year":"2004","journal-title":"Heart"},{"key":"R10-20261009","doi-asserted-by":"crossref","first-page":"1355","DOI":"10.1016\/S0735-1097(01)01564-9","article-title":"Lead aVR, a mostly ignored but very valuable lead in clinical electrocardiography.","volume":"38","author":"Gorgels","year":"2001","journal-title":"J Am Coll Cardiol"},{"key":"R11-20261009","doi-asserted-by":"crossref","first-page":"e12370","DOI":"10.1111\/anec.12370","article-title":"Predictive value of exercise stress test-induced ST-segment changes in leads V1 and avR in determining angiographic coronary involvement.","volume":"22","author":"Ghaffari","year":"2017","journal-title":"Ann Noninvasive Electrocardiol"},{"key":"R12-20261009","doi-asserted-by":"crossref","first-page":"630","DOI":"10.4330\/wjc.v6.i7.630","article-title":"Significance of lead aVR in acute coronary syndrome.","volume":"6","author":"Tamura","year":"2014","journal-title":"World J Cardiol"},{"key":"R13-20261009","doi-asserted-by":"crossref","first-page":"1348","DOI":"10.1016\/S0735-1097(01)01563-7","article-title":"Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography. 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