Background: Acute coronary syndrome (ACS) is usually associated with dynamic electrocardiographic (ECG) changes and serial ECGs can present important information, especially if the ECG at first medical contact was not informative. Objective: To achieve better management of association between ST-segment shifts in lead augmented vector right (aVR). Patients and methods: This is an observational cross-sectional study multi-center study that was conducted on patients with acute coronary syndrome in Cardiology Departments at Zagazig University Hospitals, Mansoura University Specialized Medical Hospital, and 15 May Hospital to assess the correlation between ST-elevation in lead AVR in patient with acute coronary syndrome and coronary angiographic findings. 120 patients were recruited and were as follows: 52 patients with ACS whose ECG showed ST segment elevation (STE) in lead aVR and 68 patients with ACS but without STE in lead aVR. Results: left main coronary artery (LMCA), left anterior descending (LAD), left circumflex (LCx), and right coronary artery (RCA) stenosis were significantly higher in ACS patients with STE in aVR compared to ACS patients without STE in aVR (p <0.001, 0.006, <0.001, and <0.001 respectively). 2 and 3 vessels affection were significantly higher in ACS patients with STE in aVR compared to ACS patients without STE in aVR (p =0.002 and <0.001). STE in aVR was a significant predictor for LMCA stenosis (OR: 14.67 and p value <0.001), 3 vessels disease (OR: 3.97, p value =0.004). Conclusion: STE in aVR could be used as a significant predictor for LMCA stenosis and 3 vessels disease. In addition, GABG is considered the best management to improve ASC with STE in aVR.