Identification of ST-elevation myocardial infarction is critical as early reperfusion can save myocardium and increase survival. ST-elevation (STE) in aVR, co-existent with multi-lead ST-depression, was endorsed as a sign of acute occlusion of the left main or proximal left anterior descending coronary artery in the 2013 STEMI Guidelines. We investigated the incidence of an acutely occluded coronary in patients presenting with STE-aVR with multi-lead ST-depression.