ST segment elevation in aVR is probably NOT a STEMI…BUT, damn, are they sick!

There I said it. Well Ok I’ve been saying it for a while. But say this to a room full of doctors and you might be ostracized! Well there has been mounting evidence that would argue aVR ST elevation is not an acute STEMI/ STEMI equivalent for a while now. I think this article clinches it for me. However, just because its not a STEMI equivalent doesn’t mean they are ok, nor does it mean we should forget about aVR…


In this blinded retrospective review of 99 patients with ST elevation in aVR (STE-aVR) and multi-lead ST depression, only 10% had a definite culprit lesion,  none had left main or LAD occlusions, and 40% had no disease or mild to moderate disease on PCI. However, this group had an overall in-hospital mortality of 31% compared with 6% in a matched conventional STEMI group. Patients with aVR ST elevation represent a very sick cohort of patients who need critical care and a workup for why they are having poor diffuse coronary perfusion.


This was a retrospective study with actually quite good blinding and decent methods that looked at 854 consecutive STEMI activations in a 35 month period. They identified 99 patients with ST elevation in aVR (STE-aVR) and multi-lead ST depression in the final analysis. Cardiologists reading the ECGs and catheterizations were blinded to the study outcome. The primary outcome was the number of patients presenting with STE-aVR and multilead ST depression who had an acutely occluded culprit coronary artery on PCI. Secondary outcomes were number of patients who presented with cardiac arrest, and survival-to-hospital discharge compared to the non-aVR ST elevation STEMI population. None of these 99 patients had ST elevation in 2 contiguous leads (STEMI definition). Of the original 99, 79 underwent PCI. Interestingly the 20 that did not undergo PCI were a very sick population including known severe coronary artery disease on recent coronary angiogram, neurological emergency, obvious extra-cardiac etiology for arrest, and very long down time with poor prognosis. Of the 79 patients that had PCI, 8 (10%) had evidence of a definite, acute, thrombotic, culprit coronary occlusion but none had an acutely occluded left main or left anterior descending coronary artery. 19 of these 79 had angiographically normal vessels and 40% of them had either no disease or only mild to moderate disease on PCI. However, these were a pretty sick group though: 47 developed respiratory failure, 15 developed cardiogenic shock , 48 developed acute kidney injury( 9 of them requiring hemodialysis), and 36 patients underwent in-hospital coronary revascularization (29 PCI and 7 CABG). Wow are these a sick cohort! Those with STE-aVR had a 31% in- hospital mortality, whereas those with a non-aVR STEMI had a 6.2% in-hospital mortality (p <0.00001)! The presence of a critical medical condition or severe multivessel subocclusive disease with intact distal flow was the most common etiology for this ECG finding. This emphasizes working up these patients for the underlying issue. These patients don’t likely need immediate PCI of a culprit lesion they likely need resuscitation and eventually treatment by a multi-specialty heart team for their multi-vessel disease.


Harhash, A et al. aVR ST Segment Elevation: Acute STEMI or Not? Incidence of an Acute Coronary Occlusion. The American Journal of Medicine (2019) 000:1−9. PMID: 30639554. DOI: 10.1016/j.amjmed.2018.12.021

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