This should be a striking EKG, and in fact should send shivers down your spine! There are significant ST-segment depressions in many leads (I, II, aVL, III, V2-6) as well as ST-segment elevation in aVR. This EKG is the classic example of critical left main occlusion, and should be considered a “STEMI equivalent.” This patient should be referred to interventional cardiology, as this patient was! They took him to cath, and indeed found a 99% stenosis of the left main coronary artery; they inserted an IABP to support his pressure and alleviate symptoms, and got an emergent cardiac surgery consult for CABG. The surgery was accomplished and the patient did very well.
Wellens described this EKG finding many years ago – ST-segment depression in ≥ 8 leads and ST-segment elevation in aVR. This is particularly specific if there is also ST elevation in aVL.
Lawner BJ, Nable JV, Mattu A. Novel patterns of ischemia and STEMI equivalents. Cardiol Clin 30:591-599, 2012.