ST elevation in avr dDx

ST-segment elevation in aVR with diffuse ST-segment depression in multiple other leads reflects global subendocardial ischemia of the left ventricle, often associated with proximal lesions or multi-vessel disease in patients with symptoms of cardiac ischemia. Remember, these patients typically look sick and are actively having symptoms of ACS.

It is important to recognize that there are several conditions aside from ACS that cause this ECG appearance. Clinical correlation is critical!

Here are some of the possible causes of STE in aVR (>1-1.5 mm) to consider:

Sick ACS patients (signs and symptoms of acute cardiac ischemia)

LMCA stenosis/occlusion
Proximal LAD occlusion
Triple vessel disease

Any cause of severe generalized global ischemia (Other sick non-ACS patients)

Severe anemia (e.g. GI Bleeding)
Type A dissection
Massive PE
Na⁺ channel blocker toxicity (TCA, Hyperkalemia, Brugada, etc.)
Severe hypokalemia
Early post-arrest (within 15 mins of epinephrine or defibrillation)

Normal variants

LVH with strain pattern (severe HTN)
SVT’s (esp. AVRT), rapid atrial fibrillation
LBBB, pacemakers

Check out the following links for specific differentials when dealing with diffuse STE or a comprehensive list of all causes of STE

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