ECG Case 068

Severe chest pain and hypotension (70/40) in an elderly man. Describe and interpret his ECG


Describe and interpret this ECG


This ECG shows:

  • ST elevation in aVR.
  • ST depression in multiple leads (V5-6, I, II, aVL, aVF).
  • Evidence of anteroseptal STEMI – ST elevation with Q wave formation in V1-3.

In the context of ischaemic chest pain and cardiogenic shock, the combination of…

  • Widespread ST depression
  • ST elevation in aVR > 1 mm
  • ST elevation in V1-3

… is concerning for proximal LAD occlusion (compare this to the LMCA pattern seen in Quiz ECG 008).

While this pattern of diffuse ST depression with STE in aVR if often referenced as a marker of LMCA / proximal LAD occlusion,  may be seen whenever there is diffuse severe subendocardial ischaemia, such as:

  • Severe triple vessel disease
  • Severe anaemia or hypoxaemia
  • Following resuscitation from cardiac arrest


This patient actually had severe multi-vessel disease

Angiography demonstrated a chronic total occlusion of his circumflex artery, with critical stenoses of his proximal LAD, RCA and ramus intermedius.

Surprisingly, in this case the culprit vessel was thought to be the RCA, which had been collateralising his chronically occluded circumflex. He went on to receive a CABG x 4.

TOP 100 ECG Series

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

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