# ST Elevation in aVR: An Atypical Presentation of Pulmonary Embolism

## TL;DR

ST elevation in aVR, typically linked to heart attacks, can also signal severe pulmonary embolism, requiring careful clinical evaluation to avoid misdiagnosis.

## Contribution

Highlights atypical ECG findings in pulmonary embolism and emphasizes the importance of considering PE in patients with aVR changes.

## Key findings

- ST elevation in aVR with anterolateral ST depressions was observed in a patient with pulmonary embolism.
- Echocardiography showed right ventricular dilatation, and CTPA confirmed large bilateral PEs.
- Treatment with Enoxaparin and Warfarin improved symptoms, confirming the PE diagnosis.

## Abstract

ST elevation in aVR on the electrocardiogram (ECG) indicates high‐risk acute coronary syndrome (ACS) but is rarely reported in pulmonary embolisms (PEs). We present a 47‐year‐old female with a history of PE and ankylosing spondylitis admitted for chest pain, nausea, and an episode of possible collapse. Her ECG showed ST elevation in aVR with anterolateral ST depressions, prompting a normal emergency coronary angiogram. Bedside echocardiography revealed right ventricular (RV) dilatation, and lab tests showed elevated D‐dimer levels and troponin. Urgent computed tomography of the pulmonary arteries (CTPA) confirmed large bilateral PEs. The patient was treated with Enoxaparin and transitioned to Warfarin, resulting in symptom improvement. ST‐segment elevation in lead aVR may mimic ACS but suggests significant conditions like PE, often from RV strain and impaired coronary blood flow due to acute RV failure. Clinicians should suspect PE in patients with aVR changes, especially with relevant clinical history and signs of RV pressure overload on echocardiography, to prevent misdiagnosis and ensure timely care.