ST-T wave abnormality in lead aVR and reclassification of cardiovascular risk (from the National Health and Nutrition Examination Survey-III)

Applications of digital health approaches for cardiometabolic diseases prevention and management in the Western Pacific region

Cardiometabolic diseases (CMDs) are the major types of non-communicable diseases, contributing to huge disease burdens in the Western Pacific region (WPR). The use of digital health (dHealth) technologies, such as wearable gadgets, mobile apps, and artificial intelligence (AI), facilitates interventions for CMDs prevention and treatment. Currently, most studies on dHealth and CMDs in WPR were conducted in a few high- and middle-income countries like Australia, China, Japan, the Republic of Korea, and New Zealand. Evidence indicated that dHealth services promoted early prevention by behavior interventions, and AI-based innovation brought automated diagnosis and clinical decision-support. dHealth brought facilitators for the doctor-patient interplay in the effectiveness, experience, and communication skills during healthcare services, with rapidly development during the pandemic of coronavirus disease 2019. In the future, the improvement of dHealth services in WPR needs to gain more policy support, enhance technology innovation and privacy protection, and perform cost-effectiveness research.

Clinical utility of aVR lead T-wave in electrocardiogram of patients with ST-elevation myocardial infarction

Background

aVR lead is often neglected in routine clinical practice largely because of its undefined clinical utility specifications. Nevertheless, positive T-wave in aVR lead has been reported to be associated with poor clinical outcomes in some cardiovascular diseases. This study aimed to prospectively investigate the prognostic value and clinical utility of T-wave amplitude in aVR lead in patients with acute ST-elevation myocardial infarction (STEMI).

Methods

A total of 340 STEMI patients admitted to a tertiary heart center were consecutively included. Patients were categorized into four strata, based on T wave amplitude in aVR lead in their admission ECG (i.e. < − 2, − 1 to − 2, − 1 to 0, and ≥ 0 mV). Patients’ clinical outcomes were also recorded and statistically analyzed.

Results

In-hospital mortality, re-hospitalization, and six-month-mortality significantly varied among four T wave strata and were higher in patients with a T wave amplitude of ≥ 0 mV (p 0.001–0.002). The groups of patients with higher T wave amplitude in aVR, had progressively increased relative risk (RR) of in-hospital mortality (RRs ≤ 0.01, 0.07, 1.00, 2.30 in four T wave strata, respectively). T wave amplitude in the cutoff point of − 1 mV exhibited a sensitivity and specificity of 95.83 (95% CI 78.88–99.89) and 49.68 (95% CI 44.04–55.33).

Conclusion

Our study demonstrated a significant association of positive T wave in aVR lead and adverse clinical outcomes in STEMI patients. Nevertheless, the clinical utility of T-wave amplitude at aVR lead is limited by its low discriminative potential toward prognosis of STEMI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02335-5.

Association of the positive T wave in lead aVR with short-term mortality in patients with acute pulmonary embolism

Background: Lead aVR provides prognostic information in various settings for patients with cardiovascular diseases. The present study aimed to investigate the prognostic value of a positive T wave in lead aVR (TaVR) for patients with acute pulmonary embolism (APE).Methods: We screened a total of 412 consecutive patients who were hospitalised with a diagnosis of APE between 2008 and 2018. We investigated electrocardiograms (ECGs) for the presence of a positive TaVR and classified other abnormal ECG findings. Additionally, clinical data, such as echocardiographic findings were recorded, and pulmonary embolism severity index (PESI) scores were calculated. The predictors of mortality at 30 days were investigated as the clinical outcome by logistic regression analysis.Results: In our study population, 54 patients (13.1%) died within 30 days. The prevalence of female gender, congestive heart failure, chronic obstructive pulmonary disease, and mean PESI scores were significantly higher in patients with a positive TaVR compared to those without it. Systolic blood pressure of patients with positive TaVR was significantly lower than that of patients without positive TaVR. In multivariate regression analysis; PESI scores (OR: 1.03; 95% CI: 1.01-1.04, p < .01), Right ventricular end-diastolic diameter (RVEDD) (OR: 1.07 95% CI: 1.01-1.13, p = .02), and a positive TaVR (OR: 4.41; 95% CI: 1.63-11.96, p < .01) were independently correlated with mortality.Conclusion: Positive TaVR, PESI scores, and RVEDD at hospital admission may have prognostic value in patients with APE. Positive T wave in lead aVR could be a useful marker in early risk stratification of pulmonary embolism.

Importance of lead aVR on predicting adverse cardiac events in patients with noncompaction cardiomyopathy

Background

Noncompaction cardiomyopathy (NCCM) is a relatively rare cardiac abnormality with high rates of mortality and morbidity. T‐wave amplitudes during ventricular repolarization in lead aVR (TaVR) have been reported to be associated with the prognosis of various cardiovascular diseases. This study sought to investigate the prevalence and prognostic role of positive TaVR in patients with NCCM.

Methods

We evaluated consecutive 161 patients with NCCM (65.8% men, mean age 42.5 ± 15.2 years old). Presentation electrocardiogram was assessed regarding classical parameters as well as T‐wave amplitudes in lead aVR. The primary endpoint was defined as composite lethal arrhythmic events, including sudden cardiac death, ventricular fibrillation, or sustained ventricular tachycardia or appropriate implantable cardioverter–defibrillator shock. Heart failure requiring hospitalization, cardiovascular death, and all‐cause mortality were also investigated as secondary endpoints.

Results

Patients with positive TaVR showed higher rates for arrhythmic events, hospitalization for heart failure, and death compared with patients without it. In multivariate Cox model, after adjusting for other known clinical and electrocardiographic risk factors, the positive TaVR was found to be a strong independent predictor of primary endpoint (HR: 4.8, 95% CI: 1.2–19.3; p = .025) and all‐cause death (HR: 3.5, 95% CI: 1.0–12.1; p = .045).

Conclusion

Our findings revealed that positive TaVR is significantly and independently associated with adverse outcomes in NCCM patients. This unique ECG criterion in the often ignored lead provides incremental information beyond what is available with other traditional risk factors.

The prognostic significance of a positive or isoelectric T wave in lead aVR in patients with acute coronary syndrome and ischemic ECG changes in the presenting ECG - Long-term follow-up data of the TACOS study

BACKGROUND

A positive T wave in lead aVR (aVRT+) is an independent prognostic predictor of cardiovascular mortality in the general population as well as in cardiovascular disease.

SUBJECTS AND METHODS

We evaluated the prognostic impact of aVRT+ in an ECG recorded as close to hospital discharge as possible in acute coronary syndrome patients (n = 527). We divided the patients into three categories based on the findings in the admission ECG: ST elevation, global ischemia and other ST/T changes.

RESULTS

In the whole study population, and in all the three ECG subgroups, the 10-year all-cause mortality rate was higher in the aVRT+ group than in the aVRT- group. In Cox regression analysis, the age and gender adjusted hazard ratio (HR) for aVRT+ to predict all-cause mortality in the whole study population was 1.43 (95% confidence interval [CI] 1.12-1.83; p = 0.004). To predict cardiovascular mortality, the age and gender adjusted HR for aVRT+ was 1.54 (95% CI 1.14-2.07; p = 0.005) in the whole study population and 2.07 (95% CI 1.07-4.03; p = 0.032) in the category with other ST/T changes.

CONCLUSION

In ACS patients with or without ST elevation, but with ischemic ST/T changes in their presenting ECG, a positive or isoelectric T wave in lead aVR in an ECG recorded in the subacute in-hospital stage is associated with all-cause and cardiovascular mortality during long-term follow-up. Clinicians should pay attention to this simple ECG finding at hospital discharge.

Usefulness of positive T wave in lead aVR in predicting arrhythmic events and mortality in patients with hypertrophic cardiomyopathy

BACKGROUND

Positive T wave in lead aVR (TaVR) has been associated with increased risk of adverse events in patients with various cardiovascular diseases.

OBJECTIVE

The purpose of this study was to investigate the prevalence and prognostic significance of positive TaVR in patients with hypertrophic cardiomyopathy (HCM).

METHODS

This study investigated 421 consecutive patients with HCM (177 women; age 51.1 ± 14.9 years). Admission electrocardiogram was examined for the presence of a positive TaVR. The primary endpoint was defined as a composite of major arrhythmic events (MAEs), which included sudden cardiac death, sustained ventricular tachycardia or fibrillation, or appropriate implantable cardioverter-defibrillator therapy. Cardiovascular mortality and all-cause death were evaluated as secondary endpoints.

RESULTS

During median follow-up period of 6.0 years (interquartile range 4.0-11.6 years), 53 patients (12.6%) experienced the primary endpoint. On multivariable competing analysis, after adjusting for other confounding factors, the presence of positive TaVR was found to be an independent and strong predictor of the primary composite endpoint. Time-dependent receiver operating characteristic analysis, net reclassification index, and integrated discrimination improvement showed that the addition of positive TaVR to conventional HCM risk factors improved prediction of arrhythmic events. However, in subgroup analysis, a positive TaVR lost statistical significance in patients with apical HCM but remained significant in patients with all other hypertrophy patterns.

CONCLUSION

Positive TaVR is associated with MAE in HCM patients, independent of and incremental to traditional risk factors.

The prognostic value of positive T wave in lead aVR: A novel marker of adverse cardiac outcomes in peripartum cardiomyopathy

BACKGROUND

Peripartum cardiomyopathy (PPCM) is an uncommon complication of pregnancy. Clinical courses of PPCM are markedly heterogeneous. Positive T waves in lead aVR (TaVR) are shown to be associated with adverse cardiac events in several cardiovascular diseases. We aimed to investigate the prevalence and prognostic role of positive TaVR in patients with PPCM.

METHODS

A total of 82 patients (mean age 29.1 ± 6.3 years) with the diagnosis of PPCM were enrolled. Presentation electrocardiogram (ECG) was investigated for presence of a positive TaVR. The median follow-up duration was 67.0 months. The primary endpoint was defined as composite cardiac events, including cardiac death, arrhythmic events, or persistent left ventricular systolic dysfunction.

RESULTS

Patients with positive T wave in lead aVR showed higher rates for persistent left ventricular systolic dysfunction, arrhythmic events, and cardiac death compared to patients without it. In multivariate logistic regression analysis, after adjusting for other confounding factors, the presence of positive TaVR was found to be as an independent and strong predictor of primary composite endpoint (odds ratio 6.21, 95% CI 1.45-26.51; p = 0.014). In Kaplan-Meier survival analysis, both primary and secondary endpoints occurred more frequently in the positive TaVR group. Using the cut-off level of 0.25 mV, T-wave amplitude in lead aVR predicted primary endpoint with a sensitivity of 100% and specificity of 100%.

CONCLUSION

Positive T wave in lead aVR, as a simple and feasible electrocardiographic marker, seems to be a novel predictor of adverse cardiovascular outcomes in patients with PPCM.

Usefulness of upright T wave in lead aVR for predicting short-term prognosis of patients with ischemic stroke

Background

Upright T wave in lead aVR (TaVR) has recently been reported to be associated with cardiovascular death and mortality in general population and in patients with prior cardiovascular disease (CVD). However, the evidence for the predictive ability of TaVR in patients with ischemic stroke (IS) is lacking.

Methods

A total of 625 consecutive patients with IS (mean age: 66 ± 12 years; 379 male) were enrolled in this study between January 2013 and December 2014. Patients were divided into upright TaVR (≥0 mV; n = 201) and negative TaVR (<0 mV; n = 424) groups. All patients were evaluated with respect to clinical features and in-hospital clinical results.

Results

Overall, the prevalence of upright TaVR was 32.2% at baseline. Patients with an upright TaVR were older, had a higher percentage of CVD and hypertension, higher level of MB isoenzyme of creatine kinase (CKMB), faster heart rate, higher rate of QT prolongation > 450 ms, higher rate of negative T in lead II, higher rate of negative T in lead V6, higher rate of ST depression, and longer QTc duration. During the mean follow-up period of 20.0 ± 5.8 months, 29 (4.6%) patients experienced all-cause death and 12 (1.9%) patients experienced cardiovascular death, the primary end point. Concomitantly, 94 (15%) patients experienced recurrence of IS, the secondary end point. After adjusting for clinical covariates, upright TaVR was independently associated with all-cause death [hazard ratio (HR): 2.88, 95% confidence intervals (CI): 1.07–7.73], cardiovascular death (HR: 3.04, 95% CI: 1.07–8.64), and IS recurrence (HR: 1.86, 95% CI: 1.08–3.20).

Conclusions

Upright TaVR in patients with IS is associated with increased mortality and recurrence of IS.

Prognostic value of positive T wave in lead aVR in patients with non-ST segment myocardial infarction

BACKGROUND

Lead aVR provides prognostic information in various settings in patients with ischemia. We aim to investigate the role of a positive T wave in lead aVR in non-ST segment myocardial infarction (NSTEMI).

METHODS

In a prospective cohort study, we included 400 patients with NSTEMI. Presentation electrocardiogram (ECG) was investigated for presence of a positive T wave as well as ST segment elevation (STE) in aVR and study variables were compared. Predictors of primary outcome defined as hospital major adverse cardiovascular events (MACE) and secondary outcome, defined as three-vessel coronary disease and/or left main coronary artery stenosis (3VD/LMCA) stenosis in angiography, were determined in multivariate logistic regression analysis.

RESULTS

Patients with a positive T wave in aVR were significantly older and were more likely to be female. Left ventricular ejection fraction was significantly lower in patients of positive T group. Positive T group was more likely to have 3VD/LMCA stenosis (58.3% vs. 19.8%, p < .001). The prevalence of a positive T wave in aVR was significantly higher in MACE group (54.9 % vs. 24.8%, p < .001). However, in multivariate analysis, it was not an independent predictor of MACE (OR: 1.083 95% CI: [0.496-2.365], p: .841). Though, it was independently associated with presence of 3VD/LMCA stenosis (OR: 3.747 95% CI: [2.058-6.822], p < .001).

CONCLUSION

Though positive T wave in lead aVR was more common in patients with MACE; it was not an independent predictor. Additionally, a positive T wave in aVR was an independent predictor of 3VD/LMCA stenosis in NSTEMI.

Screening for Cardiovascular Disease Risk With Electrocardiography: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Cardiovascular disease (CVD), which encompasses atherosclerotic conditions such as coronary heart disease, cerebrovascular disease, and peripheral arterial disease, is the most common cause of death among adults in the United States. Treatment to prevent CVD events by modifying risk factors is currently informed by CVD risk assessment with tools such as the Framingham Risk Score or the Pooled Cohort Equations, which stratify individual risk to inform treatment decisions.

OBJECTIVE

To update the 2012 US Preventive Services Task Force (USPSTF) recommendation on screening for coronary heart disease with electrocardiography (ECG).

EVIDENCE REVIEW

The USPSTF reviewed the evidence on whether screening with resting or exercise ECG improves health outcomes compared with the use of traditional CVD risk assessment alone in asymptomatic adults.

FINDINGS

For asymptomatic adults at low risk of CVD events (individuals with a 10-year CVD event risk less than 10%), it is very unlikely that the information from resting or exercise ECG (beyond that obtained with conventional CVD risk factors) will result in a change in the patient's risk category as assessed by the Framingham Risk Score or Pooled Cohort Equations that would lead to a change in treatment and ultimately improve health outcomes. Possible harms are associated with screening with resting or exercise ECG, specifically the potential adverse effects of subsequent invasive testing. For asymptomatic adults at intermediate or high risk of CVD events, there is insufficient evidence to determine the extent to which information from resting or exercise ECG adds to current CVD risk assessment models and whether information from the ECG results in a change in risk management and ultimately reduces CVD events. As with low-risk adults, possible harms are associated with screening with resting or exercise ECG in asymptomatic adults at intermediate or high risk of CVD events.

CONCLUSIONS AND RECOMMENDATION

The USPSTF recommends against screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at low risk of CVD events. (D recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG to prevent CVD events in asymptomatic adults at intermediate or high risk of CVD events. (I statement).

Screening for Cardiovascular Disease Risk With Resting or Exercise Electrocardiography: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Cardiovascular disease (CVD) is the leading cause of death in the United States.

OBJECTIVE

To review the evidence on screening asymptomatic adults for CVD risk using electrocardiography (ECG) to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, Cochrane Library, and trial registries through May 2017; references; experts; literature surveillance through April 4, 2018.

STUDY SELECTION

English-language randomized clinical trials (RCTs); prospective cohort studies reporting reclassification, calibration, or discrimination that compared risk assessment using ECG plus traditional risk factors vs traditional risk factors alone. For harms, additional study designs were eligible. Studies of persons with symptoms or a CVD diagnosis were excluded.

DATA EXTRACTION AND SYNTHESIS

Dual review of abstracts, full-text articles, and study quality; qualitative synthesis of findings.

MAIN OUTCOMES AND MEASURES

Mortality, cardiovascular events, reclassification, calibration, discrimination, and harms.

RESULTS

Sixteen studies were included (N = 77 140). Two RCTs (n = 1151) found no significant improvement for screening with exercise ECG (vs no screening) in adults aged 50 to 75 years with diabetes for the primary cardiovascular composite outcomes (hazard ratios, 1.00 [95% CI, 0.59-1.71] and 0.85 [95% CI, 0.39-1.84] for each study). No RCTs evaluated screening with resting ECG. Evidence from 5 cohort studies (n = 9582) showed that adding exercise ECG to traditional risk factors such as age, sex, current smoking, diabetes, total cholesterol level, and high-density lipoprotein cholesterol level produced small improvements in discrimination (absolute improvements in area under the curve [AUC] or C statistics, 0.02-0.03, reported by 3 studies); whether calibration or appropriate risk classification improves is uncertain. Evidence from 9 cohort studies (n = 66 407) showed that adding resting ECG to traditional risk factors produced small improvements in discrimination (absolute improvement in AUC or C statistics, 0.001-0.05) and appropriate risk classification for prediction of multiple cardiovascular outcomes, although evidence was limited by imprecision, quality, considerable heterogeneity, and inconsistent use of risk thresholds used for clinical decision making. Total net reclassification improvements ranged from 3.6% (2.7% event; 0.6% nonevent) to 30% (17% event; 19% nonevent) for studies using the Framingham Risk Score or Pooled Cohort Equations base models. Evidence on potential harms (eg, from subsequent angiography or revascularization) in asymptomatic persons was limited.

CONCLUSIONS AND RELEVANCE

RCTs of screening with exercise ECG found no improvement in health outcomes, despite focusing on higher-risk populations with diabetes. The addition of resting ECG to traditional risk factors accurately reclassified persons, but evidence for this finding had many limitations. The frequency of harms from screening is uncertain.

ST segment change and T wave amplitude ratio in lead aVR associated with coronary artery disease severity in patients with non-ST elevation myocardial infarction: A retrospective study

Non-ST elevation myocardial infarction (NSTEMI) severity is difficult only with electrocardiogram (ECG). In most cases, NSTEMI patients are followed with cardiac enzymes without early invasive intervention if no severe chest pain exists in the emergency department (ED) or coronary intensive care unit (CICU).Our aim was to evaluate association between CAD severity and ST segment change in lead aVR (STaVR)/T wave amplitude in lead aVR (TAaVR) ratio in patients with NSTEMI.We included 306 patients with NSTEMI in the ED between 2015 and 2016. STaVR and TAaVR values were measured from 12-derivation ECG underwent on admission to the ED. The absolute values of STaVR and TAaVR were calculated and the following were obtained; ratio 1:|STaVR|/|TAaVR|, ratio 2:|TAaVR|/|STaVR|, and ratio 3: by dividing the variable with larger absolute value to other variable with smaller absolute value (|larger value|/|smaller value|). The SYNTAX score (SS) was calculated from coronary angiography in all patients.In analysis of the bivariate correlation between SS and ratios; significantly positive, strongly with ratio 3 (r = 0.692, P < .001), and only ratio 3 was determined to be an independent predictor for SS in linear regression analysis (OR: 0.642, 95% CI: 0.432-0.853, P = .001).Severity of CAD may be estimated by evaluating STaVR and TAaVR ratio in patients with NSTEMI.

Association of Lead aVR T-wave Amplitude With Cardiovascular Events or Mortality Among Prevalent Dialysis Patients

In dialysis patients, electrocardiogram (ECG) abnormalities are common. However, the associations between the T-wave of the lead aVR (aVRT) amplitude and cardiovascular (CV) events or total mortality are unknown. We performed a prospective, observational cohort study of prevalent hemodialysis patients (N = 474), followed for 4 years. Outcomes were composite CV events and all-cause mortality. Predictors were baseline aVRT and other ECG findings. ECG parameters were analyzed in three models: model 1, univariate; model 2, basic adjustments; and model 3, model 2 plus serum albumin, C-reactive protein level, and NT-proBNP. By Cox analysis, aVRT was best associated with both endpoints through model 1 to 3 compared to other ECG findings. Patients categorized according to aVRT amplitude showed a step-by-step increase in hazard ratios for both endpoints. The aVRT amplitude level was significantly associated with not only composite CV events but also with all-cause mortality in prevalent dialysis patients.

The prognostic value of positive T-wave in lead aVR in hemodialysis patients

BACKGROUND

Given that cardiac disease is the leading cause of mortality in hemodialysis (HD) patients, identification of patients at risk for cardiac mortality is crucial. The aim of this study was to determine if positive T-wave amplitude in lead aVR (TaVR) was predictive of cardiovascular (CV) mortality and sudden cardiac death (SCD) in a group of HD patients.

METHODS AND RESULTS

After exclusion, 223 HD patients were prospectively followed-up for 25.43 ± 3.56 months. Patients were divided into TaVR negative (n = 186) and TaVR positive (n = 37) groups. Myocardial infarction, diabetes and beta-blocker therapy were more frequent in positive TaVR patients. Patients with upright TaVR were older, had higher left ventricular mass index, lower ejection fraction, higher calcium × phosphate product, higher troponin T level, higher prevalence of ST-T abnormalities, and increased width of QRS complex and QT interval, compared with patients with negative TaVR. A Kaplan-Meier analysis showed that the cumulative incidences of CV mortality as well as SCD were higher in patients with positive TaVR compared with those with negative TaVR (log-rank, p < 0.001 in both cases). A multivariate analysis selected age [hazard ratio (HR) 1.71, p < 0.001], heart rate (HR 1.42, p = 0.016), and positive TaVR (HR 2.21, p = 0.001) as well as age (HR 1.88, p < 0.001), and positive TaVR (HR 1.53, p = 0.014) as independent predictors of CV mortality and SCD, respectively.

CONCLUSION

In HD patients, positive TaVR is an independent and powerful predictor of CV mortality as well as SCD. This simple ECG parameter provides additional information beyond what is available with other known traditional risk factors and allows the identification of patients most at risk of CV events.

T-wave reversal in the augmented unipolar right arm electrocardiographic lead is associated with increased risk of sudden death

BACKGROUND

Repolarization abnormalities are associated with ventricular arrhythmias, and published studies report that a reversal of T wave polarity (positive or flat T wave) in lead aVR may be linked to increased cardiovascular mortality. We evaluated whether a positive or flat T wave in aVR is a risk marker for sudden cardiac death (SCD).

METHODS

SCD cases from the Oregon Sudden Unexpected Death Study (catchment population ~1 million) were compared to geographic controls with coronary artery disease and no history of SCD. Archived electrocardiograms performed prior and unrelated to the SCD event were evaluated.

RESULTS

SCD cases (n = 691, 67.6 ± 14.9 years, 69% male) were more likely than controls (n = 663, 66.2 ± 11.6 years, 67% male) to have diabetes (40 vs 32%; p < 0.01), left ventricular ejection fraction (LVEF) ≤35% (27 vs 11 %; p < 0.01), prolonged QTc (≥450 ms; 54 vs 28%; p < 0.01) and positive (19 vs 13%; p < 0.01) or flat T wave (14 vs 7%; p < 0.01) in aVR. On multivariable analysis, a positive/flat T wave in aVR was independently associated with SCD (OR 1.9, 95% CI 1.3-2.8, p < 0.01). However, a positive T wave alone lost statistical significance in patients with LVEF ≤ 35% and QTc ≥ 450 ms. In a subgroup analysis among patients with normal LVEF, QTc, and no diabetes, a positive T wave in aVR (but not a flat T wave) remained associated with SCD (OR 2.8, 95% CI 1.2-6.1, p < 0.01).

CONCLUSIONS

A positive or flat T wave in lead aVR was associated with SCD in subsets of patients. This simple ECG marker in this often-ignored lead may contribute to enhancement of SCD risk stratification, and warrants further evaluation.

Usefulness of an Upright T-Wave in Lead aVR for Predicting the Short-Term Prognosis of Incident Hemodialysis Patients: A Potential Tool for Screening High-Risk Hemodialysis Patients

BACKGROUND/AIMS

An upright T-wave in lead aVR (aVRT) has recently been reported to be associated with cardiovascular death and mortality among the general population and patients with prior cardiovascular disease (CVD). However, evidence for the predictive ability of aVRT in patients with chronic kidney disease is lacking. Therefore, a hospital-based, prospective, cohort study was conducted to evaluate the predictive ability of an upright aVRT for the short-term prognosis in incident hemodialysis patients.

METHODS

Among 208 patients who started maintenance hemodialysis, 79 with preexisting CVD (CVD cohort) and 129 with no history of CVD (non-CVD cohort), were studied. An upright and non-upright aVRT were defined as a wave with a positive deflection in amplitude of ≥0 mV and a negative deflection in amplitude of <0 mV, respectively. The endpoint was all-cause death.

RESULTS

Overall, the prevalence of an upright aVRT was 22.6% at baseline. During the mean follow-up period of 2.1 ± 1.0 years, 33 deaths occurred. Cumulative survival rates at 3 years after starting dialysis in patients with an upright and non-upright aVRT were 50.0 and 80.7%, respectively, in the CVD cohort and 92.0 and 91.3%, respectively, in the non-CVD cohort. In the CVD cohort, multivariate Cox regression analysis showed that an upright aVRT was an independent predictor of death after adjusting for confounding variables.

CONCLUSION

Among Japanese hemodialysis patients at high risk for CVD, an upright aVRT seems to be useful for predicting death.

The prognostic value of discordant T waves in lead aVR: A simple risk marker of sudden cardiac arrest in ischemic cardiomyopathy

BACKGROUND

Simple and reliable ECG marker(s) for sudden cardiac arrest (SCA) could be very useful in assessing high-risk populations. Since ischemic repolarization abnormalities in the left ventricular (LV) apex are strongly correlated with discordant T waves in lead aVR, we sought to evaluate the clinical and prognostic significance of this feature in ischemic cardiomyopathy.

METHODS

The PAREPET trial enrolled patients with ischemic cardiomyopathy eligible for a primary prevention implantable cardiac defibrillator (ICD). Those with persistent pacing or left bundle branch block were excluded. Amplitudes of T/aVR were automatically computed from median ECG beats at enrollment and endpoints were blindly adjudicated.

RESULTS

The sample was mainly composed of older men (n=138, age 65±12, 91% male, EF 29±9%). At enrollment, amplitude of T/aVR significantly correlated with EF, indexed LV end-diastolic volume, B-type natriuretic peptide (BNP), regional scar volume, and PET-quantified denervated myocardium. After a median follow up of 4.2years, there were 23 (17%) adjudicated SCA. In multivariate analysis, the presence of discordant T/aVR (>0mm, n=42, 30%) was a significant and independent predictor of SCA (hazard ratio 2.0 [95% CI 1.0-4.9]) and cardiac death (hazard ratio 1.9 [95% CI 1.0-3.7]).

CONCLUSIONS

In subjects with ischemic cardiomyopathy, discordant T waves in lead aVR are associated with high-risk clinical parameters including lower ejection fraction, greater ventricular volume, higher BNP, and more denervated myocardium. Furthermore, discordant T/aVR remained an independent predictor of SCA and cardiovascular mortality even after accounting for these prognostic factors.

Significance of lead aVR in acute coronary syndrome

The 12-lead electrocardiogram (ECG) is a crucial tool in the diagnosis and risk stratification of acute coronary syndrome (ACS). Unlike other 11 leads, lead aVR has been long neglected until recent years. However, recent investigations have shown that an analysis of ST-segment shift in lead aVR provides useful information on the coronary angiographic anatomy and risk stratification in ACS. ST-segment elevation in lead aVR can be caused by (1) transmural ischemia in the basal part of the interventricular septum caused by impaired coronary blood flow of the first major branch originating from the left anterior descending coronary artery; (2) transmural ischemia in the right ventricular outflow tract caused by impaired coronary blood flow of the large conal branch originating from the right coronary artery; and (3) reciprocal changes opposite to ischemic or non-ischemic ST-segment depression in the lateral limb and precordial leads. On the other hand, ST-segment depression in lead aVR can be caused by transmural ischemia in the inferolateral and apical regions. It has been recently shown that an analysis of T wave in lead aVR also provides useful prognostic information in the general population and patients with prior myocardial infarction. Cardiologists should pay more attention to the tracing of lead aVR when interpreting the 12-lead ECG in clinical practice.

Electrocardiographic deep terminal negativity of the P wave in V1 and risk of mortality: the National Health and Nutrition Examination Survey III

INTRODUCTION

Deep terminal negativity of P wave in V1 (DTNPV1), defined as negative P prime larger than one small box (1 mm, or 0.1 mV), could be easily detected by simple visual inspection of the resting 12-lead ECG. The objective of this study was to determine the relationship between DTNPV1 and all-cause-, cardiovascular disease (CVD), and ischemic heart disease (IHD) mortality in the National Health and Nutrition Examination Survey III (NHANES III).

METHODS AND RESULTS

After exclusion of participants with atrial fibrillation and missing data, DTNPV1 was automatically measured from standard 12-lead ECG in 8,146 participants. Minnesota and Novacode algorithms were used for the determination of major and minor ECG abnormalities. National Death Index was used to identify the date and cause of death. During a median follow-up of 13.8 years, a total of 2,975 deaths (1,303 CVD and 742 IHD deaths) occurred. After adjustment for age, gender, race/ethnicity, IHD, heart failure, chronic obstructive pulmonary disease, cancer, diabetes, body mass index, smoking, dyslipidemia, hypertension, use of antihypertensive and lipid-lowering medications, and ECG abnormalities, DTNPV1 was associated with significantly increased risk of all-cause death (HR [95% CI]: 1.30 [1.10, 1.53]; P = 0.002), CVD death (HR [95% CI]: 1.36 [1.08, 1.72]; P = 0.010), and IHD death (HR [95% CI]: 1.36 [1.00, 1.85]; P = 0.047).

CONCLUSION

In a large sample of the adult United States population, DTNPV1 is independently associated with increased risk of death due to all-cause, CVD, and IHD, findings suggesting its potential usefulness as a simple marker to identify individuals at risk of poor outcomes.

Neutrophil lymphocyte ratio significantly improves the Framingham risk score in prediction of coronary heart disease mortality: insights from the National Health and Nutrition Examination Survey-III

BACKGROUND

Neutrophil lymphocyte ratio (NLR) has been shown to predict cardiovascular events in several studies. We sought to study if NLR predicts coronary heart disease (CHD) in a healthy US cohort and if it reclassifies the traditional Framingham risk score (FRS) model.

METHODS

We performed post hoc analysis of National Health and Nutrition Examination Survey-III (1998-94) including subjects aged 30-79 years free from CHD or CHD equivalent at baseline. Primary endpoint was death from ischemic heart disease. NLR was divided into four categories: <1.5, ≥1.5 to <3.0, 3.0-4.5 and >4.5. Statistical analyses involved multivariate Cox proportional hazards models as well as discrimination, calibration and reclassification.

RESULTS

We included 7363 subjects with a mean follow up of 14.1 years. There were 231 (3.1%) CHD deaths, more in those with NLR>4.5 (11%) compared to NLR<1.5 (2.4%), p<0.001. Adjusted hazard ratio of NLR>4.5 was 2.68 (95% CI 1.07-6.72, p=0.035). There was no significant improvement in C-index (0.8709 to 0.8713) or area under curve (0.8520 to 0.8531) with addition of NLR to FRS model. Model with NLR was well calibrated with Hosmer-Lemeshow chi-square of 8.57 (p=0.38). Overall net reclassification index (NRI) was 6.6% (p=0.003) with intermediate NRI of 10.1% (p<0.001) and net upward reclassification of 5.6%. Absolute integrated discrimination index (IDI) was 0.003 (p=0.039) with relative IDI of 4.3%.

CONCLUSIONS

NLR can independently predict CHD mortality in an asymptomatic general population cohort. It reclassifies intermediate risk category of FRS, with significant upward reclassification. NLR should be considered as an inflammatory biomarker of CHD.