Prognostic value of lead aVR in patients with a first non-ST-segment elevation acute myocardial infarction
José A Barrabés1, Jaume Figueras, Cristina Moure
1Unitat Coronària, Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Barcelona, Spain. jabarrab@vhebron.net
Insights
ST-segment elevation in lead aVR predicts worse outcomes in non-ST-elevation myocardial infarction. This finding indicates severe coronary artery disease and may benefit from early invasive treatment.
Area of Science:
- Cardiology
- Electrocardiography
- Acute Coronary Syndromes
Background:
- ST-segment elevation in lead aVR is linked to severe coronary artery disease in acute coronary syndromes.
- The prognostic value of this ECG finding remains unclear.
Purpose of the Study:
- To investigate the prognostic significance of ST-segment elevation in lead aVR.
- To determine the association between lead aVR ST-segment elevation and coronary artery disease severity.
Main Methods:
- Analysis of initial ECGs from 775 patients with first acute myocardial infarction.
- Stratification based on the degree of ST-segment elevation in lead aVR.
- Statistical adjustment for clinical predictors and ST-segment depression.
Main Results:
- In-hospital death rates increased significantly with greater ST-segment elevation in lead aVR (1.3% vs. 8.6% vs. 19.4%).
- Adjusted odds ratios for death were 4.2 and 6.6 for moderate and severe ST elevation, respectively.
- Higher prevalence of left main or 3-vessel coronary artery disease correlated with ST-segment elevation in lead aVR (22.0% to 66.3%).
Conclusions:
- ST-segment elevation in lead aVR provides crucial short-term prognostic information in non-ST-elevation myocardial infarction.
- This ECG finding suggests more severe coronary artery disease, potentially benefiting from early invasive management.
Background:
ST-segment elevation in lead aVR has been associated with severe coronary artery lesions in patients with acute coronary syndromes, but the prognostic significance of this finding is unknown.
Methods And Results:
We analyzed the initial ECG in 775 consecutive patients admitted to our center with a first acute myocardial infarction without ST-segment elevation in leads other than aVR or V1. The rates of in-hospital death in patients without (n=525) and with 0.05 to 0.1 mV (n=116) or > or =0.1 mV (n=134) of ST-segment elevation in lead aVR were 1.3%, 8.6%, and 19.4%, respectively (P<0.001). After adjustment for the baseline clinical predictors and for ST-segment depression on admission, the odds ratios for death in the last 2 groups were, respectively, 4.2 (95% CI, 1.5 to 12.2) and 6.6 (95% CI, 2.5 to 17.6). The rates of recurrent ischemic events and heart failure during hospital stay also increased in a stepwise fashion among the groups, whereas creatine kinase-MB levels were similar. Among the 437 patients that were catheterized within 6 months, the prevalence of left main or 3-vessel coronary artery disease in the 3 groups was 22.0%, 42.6%, and 66.3%, respectively (P<0.001).
Conclusions:
Lead aVR contains important short-term prognostic information in patients with a first non-ST-segment elevation acute myocardial infarction. Because the poorer outcome predicted by ST-segment elevation in lead aVR seems to be related to a more severe coronary artery disease, an early invasive approach might be especially beneficial in patients presenting with this finding.
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