The Widow Maker

A 54 year-old male smoker is brought in by EMS with acute-onset, substernal chest pain. Vitals: BP 110/88, HR: 90. He is diaphoretic. The rest of his physical exam is unremarkable. A stat ECG reveals the following:20161101_101345

The patient is taken straight to the cardiac cath lab. Coronary angiography before and after PCI: prox-lad-occlusion



What are some of the high risk findings on this ECG?


This ECG has a few concerning findings. There are significant ST segment elevations in leads aVR, V1, V2 and aVL with diffuse ST segment depressions throughout the rest of the limb and precordial leads. The ST segment elevations in lead aVR are greater than the elevations in lead V1 and they are both rather significant elevations, greater than a few millimeters! In the setting of a rather risky patient presenting with concerning ischemic chest pain and this ECG, be concerned, be very concerned. This may be an acute coronary syndrome involving the left main coronary artery or the proximal left anterior descending coronary arteries; these are important arteries in the coronary circulation, i.e. if they go, your patient may too!

See this fantastic blog post at Life in the Fast Lane on aVR ST elevations in ACS: Also, see this post from the master Steve Smith MD at: He brings up excellent points regarding things to consider when encountering an ECG with ST segment elevations in lead aVR.

Also, note on this ECG that the ST Segment elevations in precordial leads V1 and V2 indicate that this patient is suffering from a STEMI-ACS. See this awesome post on anterior STEMIs from the masters themselves at Life in the Fast Lane  at


How would you have managed this patient in the ED?

The usual ED critical care management is key; getting IV access, getting the patient on a monitor, giving him an aspirin ASAP and getting the cardiology consultants on board are priority. This patient went on to the cardiac cath lab which demonstrated 100% occlusion of the LAD.

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