Here are a case presentation and a follow up on a patient with diffuse ST depression and ST elevation in aVR from the EMS 12-Lead blog.
A few learning points from the post:
Multi-lead ST depression with ST elevation in aVR suggest global subendocardial ischemia due to left main artery stenosis or its equivalent (multi-vessel) but not occlusion.
Rather than an unstable coronary plaque, the syndrome often reflects myocardial oxygen supply-demand imbalance in which case the troponin elevation represents a type 2 MI.
Treatment often consists of mitigating those factors causing supply-demand imbalance.
When should these patients go to the cath lab? Not always immediately, depending on clinical circumstances. That question is addressed further in this post from Dr. Smith's blog, which also discusses the much less common presentation of left main occlusion.