ECG feature of Left main coronary artery stenosis

A 58 years old male came to JIPMER hospital emergency with chief complaints of  retrosteranl chest pain since last 2 months which increased since today afternoon 12 o clock. Patient was a known case of diabetes  mellitus, hypertension since last one and half years and was on oral medication for the same. During evaluation in the emergency department patient pulse was 90 beats per minute, BP-170/100 mmhg, CVS and Respiratory system was normal. ECG of the patient done in the emergency department which is shown below.

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Image 1

ECG-Sinus rhythm at 100 beats per minute, Inferior axis nearly 90 degree in view of equiphasic QRS in lead I, there is diffuse ST segment depression with T wave inversion in lead I,II,III,avF,avL, V2-V6. There is ST segment elevation in lead avR, V1. PR interval 120 msec, QT interval 360 msec, QTc interval  464 msec.

So in a patient with DM, HTN the ECG was suggestive of acute coronary syndrome ?? NSTEMI ?? USA.Presence of ST elevation in lead avR, V1 and diffuse ST segment depression localise the lesion most likely at Left main coronary artery. Patient underwent coronary angiography which is shown below.

Image 2

Image 3

Coronary angiography of the patient suggestive of Critical left main coronary artery stenosis nearly 90-95% which confirm our ECG localisation of culprit artery.Also there were lesion in the Left anterior descending artery, Left circumflex artery, right coronary artery.

Thank you.