ST Elevation in aVR and Type 2 Myocardial Infarction

Understanding the aVR Pattern

The American College of Cardiology recommends managing STE-aVR with multilead ST depression as NSTE-ACS, not as a STEMI equivalent, due to its association with severe global myocardial ischemia, but not typically representing an acute coronary occlusion 1
The combination of ST elevation in aVR with multilead ST depression has historically been associated with left main or proximal left anterior descending coronary artery occlusion, suggesting severe global myocardial ischemia, as noted by the European Heart Journal and Circulation 2, 3
The American College of Cardiology and American Heart Association explicitly state that fibrinolytic therapy should NOT be administered to patients with ST depression when associated with ST elevation in lead aVR, reflecting recognition that this pattern does not represent a typical acute coronary occlusion requiring emergent reperfusion 4

The American College of Cardiology advises against activating the STEMI protocol for emergent catheterization in patients with STE-aVR and multilead ST depression, as this pattern does not meet STEMI criteria and rarely represents acute coronary occlusion requiring immediate reperfusion 1
The American Heart Association and American College of Cardiology recommend managing STE-aVR with multilead ST depression as NSTE-ACS, involving urgent evaluation with serial troponins, continuous ECG monitoring, and antiplatelet/anticoagulation therapy unless contraindicated 1