The aVR lead of the ECG has historically been ignored.1 However, it is helpful in the diagnosis and prognosis of many clinical situations, including acute coronary syndrome, left ventricular aneurysm, Takotsubo syndrome, supraventricular and wide-complex tachycardias, Brugada syndrome, pericarditis, tricyclic toxic effects, and pulmonary embolus.1,2
An STE in lead aVR with diffuse STD (sometimes called the aVR sign) may indicate severe left main stenosis or multivessel CAD. The higher the STE in aVR, the higher the mortality.3 An AMI due to severe proximal LAD stenosis may cause STE in aVR; however, STE in V1 will exceed that in aVR, and diffuse STD is less common. This patient’s ECG may be similar to a variant type of inferior myocardial infarction reported by Aslanger et al.4 The pattern includes STE in lead III (but not leads I or II) along with STE in aVR and lateral STD in the presence of severe multivessel CAD. However, in the variant pattern described by Aslanger et al,4 STD is absent in lead V2, but it was present in this patient. The etiology for the STE in aVR was probably either reciprocal changes caused by STD in the anterolateral leads and/or infarction of the basal septum.