Diffuse ST depression, and ST elevation in aVR. Left main, right?

This ECG was recorded on a middle-aged male with sickle cell disease and diffuse pain.Sinus rhythmLeft ventricular hypertrophy (LVH)Diffuse significant ST depression with ST Elevation in aVRComputerized QT = 494 ms, QTc = 538 msWhat else?What do you think?Here is a Previous ECG for comparison:Baseline LVHOnly minimal ST depressionDiffuse ST depression with ST Elevation in aVRKnotts et al. found that such ECG findings only represented left main ACS in 14% of such ECGs: Only 23% of patients with the aVR STE pattern had any LM disease (fewer if defined as  ≥ 50% stenosis). Only 28% of patients had ACS of any vessel, and, of those patients, the LM was the culprit in just 49% (14% of all cases).  It was a baseline finding in 62% of patients, usually due to LVH. Reference: Knotts RJ, Wilson JM, Kim E, Huang HD, Birnbaum Y. Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease? J Electrocardiol 2013;46:240-8.Hypokalemia is frequently forgotten as a cause of ST depression.The ST depression is accompanied by what appear to be down-up T-waves diffusely.  The " up " portion is really a U-wave.  Whenever there are down-up T-waves and what appears to be an extremely long QT, you must suspect that the " Up " wave is a U-wave and that this is hypokalemia. When there is ST depression, one must:1.  Assess the QRS.  It the abnormal repolarization (S...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs