Slide 1: 50-year-old male. Chest pain x5 hours. [EKG] What’s the scariest finding on this strip?

Slide 2: Hint: check out the AVR lead. [EKG showing ST elevation in AVR]

Slide 3: aVR: a lead not to neglect. ST-elevations in aVR with diffuse ST-depressions elsewhere may point to: A critical stenosis of the left main coronary artery OR significant 3-vessel coronary artery disease.

Slide 4: When the history is suggestive of ACS, “ST-elevation in aVR has been demonstrated to be the single most powerful ECG predictor of significant LMC artery stenosis and multi-vessel disease, clearly outperforming other parameters such as TIMI score, troponin I, and N-terminal pro hormone of brain natriuretic peptide levels.”

Slide 5: Got any cool EKGs? Email us at with your learning byte!


  • Brenes-Salazar JA. ST-Segment Elevation in Lead aVR: A Visual Reminder of Potential Catastrophe. JAMA Intern Med. 2018 Jun 1;178(6):847-848. PMID 29610833

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