The forgotten lead: does aVR ST-deviation add insight into the outcomes of ST-elevation myocardial infarction
Aws Alherbish1, Cynthia M Westerhout, Yuling Fu
1Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
Insights
ST-segment deviation in lead aVR is common in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention. This deviation independently predicts 90-day mortality, with location-specific risks for ST-elevation and ST-depression.
Area of Science:
- Cardiology
- Clinical Electrocardiography
- Acute Coronary Syndromes
Background:
- ST-segment deviation in lead aVR is a known predictor of mortality in ST-elevation myocardial infarction (STEMI) treated with fibrinolysis.
- Its prognostic significance in patients undergoing primary percutaneous coronary intervention (PCI) remains unclear.
Purpose of the Study:
- To investigate the prognostic value of lead aVR ST-segment deviation in STEMI patients treated with primary PCI.
- To determine if MI location modifies the association between aVR ST-deviation and mortality.
Main Methods:
- Analysis of 5,683 STEMI patients from the APEX-AMI trial presenting within 6 hours of symptom onset.
- Baseline 12-lead ECGs were analyzed by a core laboratory, blinded to treatment and outcomes.
- Multivariable analysis was used to assess the association between aVR ST-deviation and 90-day mortality.
Main Results:
- Lead aVR ST-deviation was observed in one-third of STEMI patients and was significantly associated with increased 90-day mortality.
- Lead aVR ST-elevation (ST-E) was strongly linked to 90-day death in inferior MI (aHR 5.87), while ST-depression (ST-D) was associated with excess mortality in non-inferior MI (aHR 1.53).
- Lead aVR ST-E was also associated with a higher prevalence of left main and multivessel coronary artery disease.
Conclusions:
- Lead aVR ST-deviation is a common and independent predictor of 90-day mortality in STEMI patients treated with primary PCI.
- The prognostic impact of aVR ST-deviation is modulated by MI location, identifying high-risk groups with inferior MI (ST-E) and non-inferior MI (ST-D).
- Patients with lead aVR ST-E more frequently had advanced coronary artery disease.
Background:
Lead aVR ST-segment deviation has been associated with increased mortality in ST-elevation myocardial infarction patients treated with fibrinolysis. However, its prognostic value in a contemporaneous population undergoing primary percutaneous coronary intervention is unknown.
Methods And Results:
A core laboratory examined the 12-lead baseline electrocardiogram in 5,683 patients presenting within 6 hours of symptom onset in the APEX-AMI trial, and readers were blinded to study treatment and clinical outcomes. aVR ST-deviation was significantly associated with 90-day death when compared with patients with no aVR ST-deviation (aVR ST-depression [ST-D] 5%, aVR ST-elevation [ST-E] 10.2%, no ST-deviation [N] aVR 3.8%, P < .001). After multivariable adjustment, aVR ST-E was strongly associated with 90-day death in inferior myocardial infarction (MI) (adjusted hazard ratio [HR] 5.87, 95% CI 2.09-16.5), whereas aVR ST-D was associated with excess mortality in noninferior MI (1.53, 1.06-2.22; P [interaction] < .001). aVR ST-E was also significantly associated with the presence of left main coronary (N aVR 1.8%, aVR ST-E 7.7%, P ≤ .001) and multivessel coronary disease (N aVR 41.3%, aVR ST-E 53.3%, P ≤ .001).
Conclusions:
Lead aVR ST-deviation is common, occurring in one-third of all ST-elevation myocardial infarction patients and independently associated with increased 90-day death. Myocardial infarction location modulates the prognostic significance of aVR ST-deviation such that lead aVR ST-E in inferior MI and ST-D in noninferior MI represent 2 high-risk groups. There was also more frequent advanced coronary disease in patients with aVR ST-E.
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