Significance of ST-Segment Elevation in Lead aVR—Quiz Case

A 69-YEAR-OLD MAN WITH A HISTORY OF HYpertension, hyperlipidemia, active tobacco smoking (35 pack-years), and atrial flutter status post successful electrical cardioversion self-presented to the emergency department for 1 month of progressively worsening dyspnea on exertion and 2 days of frequent episodes of exertional and nonpleuritic mid-sternal chest pressure. He did not have a known history of coronary artery disease or diabetes mellitus, although there was a paternal history of fatal myocardial infarction at age 54 years. The patient was asymptomatic at the time of presentation and an electrocardiogram (ECG) was obtained (Figure 1). The ECG was remarkable for 1-mm ST-segment elevation in lead aVR, submillimeter STsegment elevation in lead V1, and ST-segment depressions in leads II, III, aVF, and V4 through V6. Questions: Are the noted ECG findings concerning for a critical coronary artery lesion? What is the most appropriate next step in evaluation and management?