Acute Coronary Syndrome with ST Elevation in aVR and V1

Diagnostic Interpretation

The European Society of Cardiology recommends that ST elevation in aVR combined with V1, particularly when accompanied by widespread ST depression in eight or more leads, strongly suggests left main coronary artery or proximal multivessel disease and warrants immediate coronary angiography regardless of troponin results 1
The American Heart Association suggests that proximal left anterior descending (LAD) occlusion should be considered when ST elevation extends to leads I, aVL, V1-V4 with reciprocal ST depression in inferior leads (II, III, aVF) 2
Patients presenting with this ECG pattern and hemodynamic compromise (hypotension, shock, pulmonary edema) are at high risk for adverse outcomes 1

The American College of Cardiology recommends obtaining a 12-lead ECG within 10 minutes of first medical contact and identifying ST elevation in aVR and V1 with widespread ST depression 1, 3
Immediate activation of the catheterization laboratory is recommended, without waiting for troponin results, in patients with this high-risk ECG pattern 1, 4
Aspirin 150-300 mg (non-enteric coating) should be administered immediately, followed by a P2Y12 inhibitor (prasugrel 60 mg or ticagrelor 180 mg preferred over clopidogrel) and parenteral anticoagulation (unfractionated heparin or bivalirudin) 4

The European Heart Journal suggests that patients with ST elevation in aVR and V1, but without acute occlusion, may still require urgent coronary angiography due to high in-hospital mortality (31%) and prevalence of severe coronary disease (59%) 5
Hemodynamic stability should be assessed, and if the patient has cardiogenic shock, chest pain, or electrical instability, immediate catheterization is recommended 4, 5

Patients with this ECG pattern are at high risk for adverse outcomes, including 31% in-hospital mortality, 59% with severe multivessel coronary disease, and high risk for cardiogenic shock and malignant arrhythmias 4, 5
The American Heart Association recommends continuous hemodynamic monitoring, including blood pressure and arterial line placement, and assessing for signs of cardiogenic shock 4, 5

Patients with prior CABG and this ECG pattern may represent acute vein graft occlusion, and emergency angiography is indicated 1
The American College of Cardiology recommends considering mechanical circulatory support early in patients with cardiac arrest and this ECG pattern 4