Iatrogenic ostial left main coronary artery stenosis identified by ST elevation in ECG lead aVR during stress testing – “Revisiting the no man's land”

A 60-year-old diabetic male underwent a diagnostic coronary angiogram followed by angioplasty of the left circumflex coronary artery. Two months after the procedure, he presented with atypical chest pain and exercise stress testing done revealed ST elevation in lead aVR and ST depressions in multiple leads at 5.7 METS. Coronary angiogram done revealed ostial stenosis of the left main coronary artery, which in this case was attributed to an occult injury during the angioplasty procedure. ST elevation in lead aVR during stress testing is a neglected yet useful sign for recognition of LMCA stenosis as is illustrated in this case.