aVR ST elevation: an important but neglected sign in ST elevation acute myocardial infarction
Cheuk-Kit Wong1, Wanzhen Gao, Ralph A H Stewart
1Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
Insights
ST elevation in the aVR lead during ST elevation acute myocardial infarction (AMI) indicates a higher risk of mortality. This finding holds true regardless of the infarction
Area of Science:
- Cardiology
- Clinical Electrocardiography
- Acute Myocardial Infarction
Background:
- ST elevation acute myocardial infarction (AMI) is a critical condition requiring prompt diagnosis and risk stratification.
- The prognostic value of specific electrocardiographic findings, such as ST elevation in the aVR lead, is an area of ongoing research.
Purpose of the Study:
- To evaluate the prognostic significance of aVR ST elevation in patients with ST elevation acute myocardial infarction (AMI).
Main Methods:
- Analysis of data from the Hirulog and Early Reperfusion/Occlusion-2 study, involving 17,073 patients with ST elevation AMI.
- Electrocardiographic recordings were analyzed for aVR ST elevation in relation to 30-day mortality.
- Statistical adjustments were made for summed ST elevation and ST depression in other leads.
Main Results:
- aVR ST elevation (≥1 mm) was associated with significantly higher 30-day mortality in patients with normal intraventricular conduction, irrespective of AMI location.
- Adjusted analyses revealed increased mortality odds with aVR ST elevation (≥1.5 mm for anterior AMI, ≥1 mm for inferior AMI).
- Resolution of aVR ST elevation post-therapy correlated with lower mortality, while new or persistent elevation indicated higher risk.
Conclusions:
- ST elevation in the aVR lead is a significant adverse prognostic marker in ST elevation acute myocardial infarction (AMI).
- aVR ST elevation provides valuable risk stratification information, independent of infarct location.
- Monitoring changes in aVR ST elevation during treatment can inform patient outcomes.
Aim:
This study evaluated the prognostic implications of aVR ST elevation during ST elevation acute myocardial infarction (AMI).
Methods And Results:
The Hirulog and Early Reperfusion/Occlusion-2 study randomized 17 073 patients with acute ST elevation AMI within 6 h of symptom onset to receive either bivalirudin or heparin, in addition to streptokinase and aspirin. The treatments had no effect on the primary endpoint of 30-day mortality. Electrocardiographic recordings were performed at randomization and at 60 min after commencing streptokinase. aVR ST elevation > or =1 mm was associated with higher 30-day mortality in 15 315 patients with normal intraventricular conduction regardless of AMI location (14.7% vs. 11.2% for anterior AMI, P = 0.0045 and 16.0% vs. 6.4% for inferior AMI, P < 0.0001). After adjusting for summed ST elevation and ST depression in other leads, associations with higher mortality were found with aVR ST elevation of > or =1.5 mm for anterior [odds ratio 1.69 (95% CI 1.16 to 2.45)] and of > or =1 mm for inferior AMI [odds ratio 2.41 (95% CI 1.76 to 3.30)]. There was a significant interaction between aVR ST elevation and infarct location. Thirty-day mortality was similar with anterior and inferior AMI when aVR ST elevation was present (11.5% vs. 13.2%, respectively, P = 0.51 with 1 mm and 23.5% vs. 22.5% respectively, P = 0.84 with > or = 1.5 mm ST elevation). After fibrinolytic therapy, resolution of ST elevation in aVR to <1 mm was associated with lower mortality, while new ST elevation > or =1 mm was associated with higher mortality.
Conclusion:
aVR ST elevation is an important adverse prognostic sign in AMI.
Related Concept Videos
01:30Acute Coronary Syndrome I: Introduction
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:26Acute Coronary Syndrome V: Nursing Management
01:22Aortic Regurgitation II: Clinical Features and Diagnostic Tests
01:27Myocarditis II: Clinical Features and Diagnostic Tests