Scenario: The following 12-lead electrocardiogram (ECG) was obtained from a 71-year-old woman who called 9-1-1 for new onset acute chest pain associated with dyspnea. She had no significant cardiac history. The paramedics transmitted this prehospital ECG to a medical command physician, requesting specific medical directions. What is your assessment of this ECG?

Sinus tachycardia with ST-segment elevation in lead aVR and profound ST-segment depression in multiple leads, consistent with severe left main coronary artery disease and/or possibly occlusion of the left anterior descending coronary artery (LAD). These findings are consistent with high-risk acute coronary syndrome (ACS), and the patient should be transported emergently to a tertiary care hospital that can provide primary percutaneous coronary intervention.

Lead aVR is the augmented unipolar right arm lead, which is the only lead that opposes the direction of the main cardiac vector. This “view” makes...

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