Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease?

Background and PurposeWe assess whether the electrocardiographic (ECG) pattern of ST depression in > 7 body surface leads combined with ST elevation in aVR and V1 is predictive of left main coronary artery (LMCA) stenosis or left main equivalent (LMEQ) disease.MethodsWe collected 133 patients showing this particular ECG pattern. Patients with left bundle branch block, ventricular rhythm or ventricular paced rhythm were excluded.ResultsOnly 28% of the patients had non-ST elevation acute coronary syndrome (NSTE-ACS). ECGs were classified as chronic, dynamic or no prior in 28%, 48% and 24%, respectively. A total of 57 patients (44%) underwent coronary angiography (CA). No significant coronary artery disease was found in 26%. LMCA/LMEQ disease was found in only 23% of these patients. The positive predictive value of the ECG pattern was not improved after exclusion of patients with intraventricular conduction abnormalities and left ventricular hypertrophy or in patients with dynamic ECG changes.ConclusionsThis ECG pattern is not always caused by LMCA/LMEQ disease; therefore, the term “suspect circumferential subendocardial ischemia” may be preferred. Other medical conditions may also be associated with a similar ECG pattern.