Potential of R Wave in aVL Lead in Cardiovascular Risk Assessment

Background: R wave amplitude in the aVL ECG lead (R_aVL) has been identified as a marker of cardiovascular (CV) risk, hypertension-mediated target organ damage (HMOD), and mortality in patients with arterial hypertension (AH), where R_aVL > 1.1 mV suggests left ventricular hypertrophy. However, the exact threshold for identifying high-risk patients has yet to be determined. Therefore, we compared R_aVL values among hypertensive patients with and without hypertensive urgencies (HUs) and healthy subjects, aiming to identify the predictors of elevated R_aVL and to compare its prognostic value with the SCORE 2 model. Methods: This cross-sectional study included 339 participants divided into three groups according to ambulatory blood pressure monitoring results: 100 patients with AH and HU from the emergency department, 134 patients with AH without HU, and 105 healthy subjects recruited from four family medicine practices. Basic laboratory parameters were determined, SCORE 2 risk was calculated, PWV was measured using oscillometry, and a standard 12-lead ECG was recorded in all participants. Results: Participants with AH and HU had the highest R_aVL values compared to those with AH without HU and healthy subjects (averages of 0.76 ± 0.24 mV, 0.49 ± 0.27, 0.22 ± 0.25, respectively; p < 0.001). Significantly higher R_aVL values were observed in males compared to females (0.56 ± 0.31 vs. 0.41 ± 0.34 mV; p < 0.001) and in non-dippers compared to dippers (0.56 ± 0.34 mV vs. 0.41 ± 0.31 in dippers; p < 0.001). Age, mean arterial pressure, PWV, and SCORE 2 were shown as independent predictors of R_aVL. Compared with SCORE 2, individuals with R_aVL > 0.40 mV had high CV risk (sensitivity of 58.16%, specificity of 73.68%; p < 0.001). Conclusions: In this study, R_aVL demonstrated good prognostic value for CV risk stratification. However, larger studies are needed to determine a precise high-risk threshold to improve CV risk estimation and HMOD detection in patients with marginal SCORE 2 CV risk.