Lead augmented vector right T wave and elevated E/e' ratio identify hemodialysis patients at high cardiovascular risk

This study was performed to evaluate the prognostic utility of a positive T wave in lead augmented vector right (TaVR) and elevated E/e' ratio in predicting major adverse cardiovascular events (MACE) in patients receiving maintenance hemodialysis.

We retrospectively examined 296 adults on thrice-weekly hemodialysis with baseline electrocardiography and transthoracic echocardiography (October 2018-April 2024). TaVR positivity was T-wave amplitude, >0 mV and high E/e', ≥19. Primary outcome was the first MACE-cardiovascular death, myocardial infarction, stroke, heart-failure admission, or revascularization. Multivariable Cox models adjusted for clinical covariates; incremental value was gauged with Harrell's C-index, integrated discrimination improvement (IDI), and continuous net reclassification improvement (NRI). Sensitivity analysis was performed using a guideline-recommended E/e' threshold of ≥15 to assess robustness.

Over 56.5 months (1,325 patient-years), 118 MACE occurred (8.9/100 patient-years). Incidence was higher with TaVR positivity than negativity (16.0/100 patient-years vs. 3.7/100 patient-years; log-rank p < 0.001). Adjusted hazard ratios were 3.19 (95% confidence interval [CI], 2.00-5.08) for TaVR and 2.92 (95% CI, 1.71-4.96) for high E/e'. Adding both markers to the clinical model increased the C-index from 0.65 to 0.75 (Δ 0.10) and improved IDI (0.10) and NRI (0.16) (all p < 0.01). A significant negative interaction (hazard ratio, 0.21; p = 0.01) indicated complementary but partly overlapping information. Sensitivity results were similar.

TaVR positivity is a strong independent electrocardiography predictor of cardiovascular events in hemodialysis. Combining TaVR with E/e' adds prognostic value and supports a pragmatic two-step strategy- electrocardiography triage followed by focused echocardiography-for cardiovascular risk stratification in this high-risk population.