ST elevation in ECG lead aVR signals severe acute left main coronary artery disease

Patients with suspected acute coronary syndrome are commonly assessed by acute physicians on arrival in hospital. Although most will recognise the typical ECG features of ST elevation myocardial infarction, the significance of ST elevation in lead aVR may not always be appreciated. This case series describes 6 cases in which this ECG abnormality was the predominant feature in patients whose subsequent angiogram revealed severe acute left main coronary artery disease. The importance of early referral of such patients to a centre in which percutaneous coronary intervention can be performed, is discussed.