Predictive Value of ST-Segment Elevation in Lead aVR for Left Main and/or Three-Vessel Disease in Non-ST-Segment Elevation Myocardial Infarction

Early predictors of severe left main and/or three-vessel disease in patients with non-ST-segment elevation myocardial infarction: A dual-center retrospective study

BACKGROUND

Early detection of patients concomitant with left main and/or three-vessel disease (LM/3VD) and high SYNTAX score (SS) is crucial for determining the most effective revascularization options regarding the use of antiplatelet medications and prognosis risk stratification. However, there is a lack of study for predictors of LM/3VD with SS in patients with non-ST-segment elevation myocardial infarction (NSTEMI). We aimed to identify potential factors that could predict LM/3VD with high SS (SS > 22) in patients with NSTEMI.

METHODS

This dual-center retrospective study included a total of 481 patients diagnosed with NSTEMI who performed coronary angiography procedures. Clinical factors on admission were collected. The patients were divided into non-LM/3VD, Nonsevere LM/3VD (SS ≤ 22), and Severe LM/3VD (SS > 22) groups. To identify independent predictors, Univariate and logistic regression analyses were conducted on the clinical parameters.

RESULTS

A total of 481 patients were included, with an average age of 60.9 years and 75.9% being male. Among these patients, 108 individuals had severe LM/3VD. Based on the findings of a multivariate logistic regression analysis, the extent of ST-segment elevation observed in lead aVR (OR: 7.431, 95% CI: 3.862-14.301, p < .001) and age (OR: 1.050, 95% CI: 1.029-1.071, p < .001) were identified as independent predictors of severe LM/3VD.

CONCLUSION

This study indicated that the age of patients and the extent of ST-segment elevation observed in lead aVR on initial electrocardiogram were the independent predictive factors of LM/3VD with high SS in patients with NSTEMI.

The prognostic effect of ST-elevation in lead aVR on coronary artery disease, and outcome in acute coronary syndrome patients: a systematic review and meta-analysis

BACKGROUND

Rapid diagnosis of coronary artery disease has an important role in saving patients. The aim of this study is to evaluate if aVR lead ST-elevation (STE) can predict LM/3VD, left main (LM) disease, and three-vessel disease (3VD), outcome in acute coronary syndrome (ACS) patients.

METHODS

In this systematic review and meta-analysis, 45 qualified studies were entered. Scopus, Pub med, Google scholar, Web of science, Cochrane library were searched on 12 November 2021.

RESULTS

This systematic review includes 52,175 participants. In patients with STE, the total odds ratios for LM, 3VD, and LM/3VD were 5.48 (95% CI 3.88, 7.76), 2.21 (95% CI 1.78, 3.27), and 6.21 (95% CI 3.49, 11,6), respectively. STE in lead aVR was linked with in-hospital death (OR = 2.99, CI 1.90, 4.72) and 90-day mortality (OR = 3.09, CI 2.17, 4.39), despite the fact that it could not predict 30-day mortality (OR = 1.11, CI 0.95, 1.31). The STE > 1 mm subgroup had the highest sensitivity for LM (0.9, 95% CI 0.82, 0.98), whereas the STE > 0.5 mm (0.76, 95% CI 0.61, 0.90) subgroup had the highest sensitivity for LM/3VD. The appropriate cut-off point with highest specificity for LM/3VD and LM was STE > 1.5 mm (0.80, 95% CI 0.75, 0.85) and STE > 0.5 mm, respectively (0.75, 95% CI 0.67, 0.84, I² = 97%).

CONCLUSION

The odds of LM and LM/3VD were higher than 3VD in ACS patients with STE in lead aVR. Also, STE > 0.5 mm was the best cut-off point to screen LM/3VD, whereas for LM diagnosis, STE > 1 mm had the highest sensitivity. Furthermore, LM/3VD had a higher overall specificity than LM.

Predictive value of ST-segment deviation in aVR in patients suffering from acute coronary syndrome: A retrospective cohort study

Changes in the ST-segment in aVR of electrocardiogram have been used to predict the morbidity of left main and/or 3-vessel disease (LM/3-VD) in patients with acute coronary syndrome (ACS). However, the association with patient prognosis has rarely been reported. A total of 274 patients diagnosed with ACS were retrospectively evaluated following allocation into 1 of 3 groups: the ST-segment elevation (STE) group ≥ 0.05 mV, ST-segment depression (STD) group ≥ 0.05 mV, and the Isoelectric group in aVR. A comparison of clinical characteristics, coronary angiography results, major adverse cardiovascular events (MACE), and GRACE risk score was made. Patients in the STE and STD groups were older and had a lower LVEF, a greater number of MACE and higher GRACE risk score, compared with patients in the isoelectric group. Patients in the STE group had significantly greater morbidity due to LM/3-VD than did the non-STE groups. In addition, as the amplitude of STE in aVR increased, the number of MACE, GRACE risk score, and the incidence of LM/3-VD increased. Furthermore, after adjusting for other clinical factors, multivariate statistical results indicated that STE ≥ 0.05 mV in aVR was the only predictor of LM/3-VD, whereas STD ≥ 0.05 mV was not. It was found that STE or STD ≥ 0.05 mV in aVR was an independent predictor of MACE. STE ≥ 0.05 mV in aVR is associated with LM/3-VD. Furthermore, ST-segment deviation in aVR may have prognostic value of MACE and associated with higher GRACE risk scores in patients with ACS.

The utility of SYNTAX score predictability by electrocardiogram parameters in patients with unstable angina

Background

SYNTAX score is one of the risk assessment systems to predict cardiac events in acute coronary syndrome patients. Despite the large number of SYNTAX score benefits, invasive methods such as coronary angiography are necessary to perform the scoring. We hypothesized that ECG parameters could predict the SYNTAX score in unstable angina patients.

Methods

During the retrospective cohort study, a total number of 876 patients were diagnosed with unstable angina. After applying the exclusion criteria, 600 patients were divided into tertiles based on the SYNTAX scores as low (0–22), intermediate (23–32), and high (≥ 33). The association between ECG parameters and SYNTAX score was investigated.

Results

The study included 65% men and 35% women with a mean age of 62.4 ± 9.97 years. The delayed transition zone of QRS complex, ST-depression in inferior-lateral territories or/and in all three territories, and T-wave inversion in lateral territory were significant (p < 0.05) independent predictors of intermediate SYNTAX score. High SYNTAX score was predicted by the presence of prolonged P wave duration, ST-depression in lateral territory or/and anterior-lateral territories, ST-elevation in aVR–III leads or/and aVR–III–V1 leads. Among those, all three territories ST-depression (AUC: 0.611, sensitivity: 75%, specificity: 51%) and aVR + III ST-elevation (AUC: 0.672, sensitivity: 50.12%, specificity: 80.50%) were the most accurate parameters to predict intermediate and high SYNTAX scores, respectively.

Conclusion

The present study demonstrates that accompanying the STE in the right side leads (aVR, III, V1) with ST-depression in other leads indicates the patients with high SYNTAX score; meanwhile, diffuse ST-depression without ST-elevation is a marker for intermediate SYNTAX score in unstable angina patients and can be applied for early risk stratification and intervention.

STEMI Equivalents and Their Incidence during EMS Transport

Objective: The management of patients with ST-elevation myocardial infarction (STEMI) is time-critical, with a focus on early reperfusion to decrease morbidity and mortality. It is imperative that prehospital clinicians recognize STEMI early and initiate transport to hospitals capable of percutaneous coronary intervention (PCI) with a door-to-balloon time of ≤90 minutes. Three patterns have been identified as STEMI equivalents that also likely warrant prompt attention and potentially PCI: Wellens syndrome, De Winter T waves, and aVR ST elevation. The goal of our study was to assess the incidence of these findings in prehospital patients presenting with chest pain. Methods: We conducted a retrospective chart review from a large urban tertiary care emergency department. We reviewed the prehospital ECG, or ECG upon arrival, of 861 patients who were hospitalized and required cardiac catheterization between 4/10/18 and 5/7/19. Patients who had field catheterization lab activation by EMS for STEMI were excluded. If a prehospital ECG was not available for review, the first ECG obtained in the hospital was used as a proxy. Each ECG was screened for aVR elevation, De Winter T waves, and Wellens syndrome. Results: Of 278 charts with prehospital ECGs available, 12 met our criteria for STEMI equivalency (4.4%): 6 Wellens syndrome and 6 aVR STEMI. There were no cases of De Winters T waves. Of 573 charts with no prehospital ECG available, 27 had initial hospital ECGs that met our STEMI equivalent criteria (4.7%): 7 Wellens syndrome and 20 aVR STEMI. Again, there were no cases of De Winters T waves. Conclusions: These preliminary data suggest that there are significant numbers of patients whose prehospital ECG findings do not currently meet criteria for field activation of the cardiac catheterization lab, but who may require prompt catheterization. Further studies are needed to look at outcomes, but these results could support the need for further education of prehospital clinicians regarding recognition of these STEMI equivalents, as well as quality initiatives aimed at decreasing door-to-balloon time for patients with STEMI equivalents.

Prognostic implications of ST-segment elevation in lead aVR in patients with acute coronary syndrome: A meta-analysis

BACKGROUND

ST-segment elevation (STE) in lead aVR is a useful tool in recognizing patients with left main or left anterior descending coronary obstruction during acute coronary syndrome (ACS). The prognostic implication of STE in lead aVR on outcomes has not been established.

METHODS

We performed a systematic search for clinical studies about STE in lead aVR in four databases including PubMed, EMBASE, Cochrane Library, and Web of Science. Primary outcome was in-hospital mortality. Secondary outcomes included in-hospital (re)infarction, in-hospital heart failure, and 90-day mortality.

RESULTS

We included 7 studies with a total of 7,700 patients. The all-cause in-hospital mortality of patients with STE in lead aVR during ACS was significantly higher than that of patients without STE (OR: 4.37, 95% CI 1.63 to 11.68, p = .003). Patients with greater STE (>0.1 mV) in lead aVR had a higher in-hospital mortality when compared to lower STE (0.05-0.1 mV) (OR: 2.00, 95% CI 1.11-3.60, p = .02), However, STE in aVR was not independently associated with in-hospital mortality in ACS patients (OR: 2.72, 95% CI 0.85-8.63, p = .09). The incidence of in-hospital myocardial (re)infarction (OR: 2.77, 95% CI 1.30-5.94, p = .009), in-hospital heart failure (OR: 2.62, 95% CI 1.06-6.50, p = .04), and 90-day mortality (OR: 10.19, 95% CI 5.27-19.71, p < .00001) was also noted to be higher in patients STE in lead aVR.

CONCLUSIONS

This contemporary meta-analysis shows STE in lead aVR is a poor prognostic marker in patients with ACS with higher in-hospital mortality, reinfarction, heart failure and 90-day mortality. Greater magnitude of STE portends worse prognosis. Further studies are needed to establish an independent predictive role of STE in aVR for these adverse outcomes.

Is isolated ST segment elevation in Lead aVR associated with high grade coronary artery disease?

BACKGROUND

The diagnostic accuracy of lead aVR ST-segment elevation for left main or triple vessel disease (LM/3VD) has not been universally accepted. In the present analysis we sought to evaluate the diagnostic accuracy of STEaVR in patients presenting with an acute coronary syndrome (ACS).

METHODS

Pooled sensitivity, specificity, positive, and negative likelihood ratios were calculated using a random effects model (DerSimonian-Laird Method) for computing summary estimates and receiver operator curve (ROC) analysis for evaluating overall diagnostic accuracy.

RESULTS

This meta-analysis included 14 studies. The pooled sensitivity of STEaVR for LM/3VD was 0.40 (95% CI; 0.38 0.43, p < 0.001), specificity 0.82 (95% CI; 0.81-0.83, p < 0.001). Pooled positive likelihood ratio 2.49 (95% CI; 1.62-3.81, p < 0.001) and negative likelihood 0.54 (95% CI; 0.39-0.76, p < 0.001). The pooled sensitivity of STEaVR for LM was 0.39 (95% CI; 0.34-0.45, p < 0.001) specificity was 0.86 (95% CI; 0.85-0.87, p < 0.001) with an AUC of 0.79. The pooled positive likelihood ratio (LR) for LM was 2.78 (95% CI, 2.28-3.39, p < 0.001) negative likelihood ratio 0.51 (95% CI, 0.33-0.78, p < 0.001).

CONCLUSION

Our study shows that in patients presenting with an ACS, presence of STEaVR may indicate the presence of LM or 3VD. STEaVR has a high specificity for both LM and 3VD, with a high pooled LR.

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.

Value of ST-segment change in lead aVR in diagnosing left main disease in Non-ST-elevation acute coronary syndrome-A meta-analysis

BACKGROUND

Previous researches proved that the ST-segment elevation (STE) in lead aVR had great significance on the prediction of severe left main lesion or serious multivessel lesions. The current research is to summarize the published data and evaluate the overall association of STE in lead aVR and left main coronary artery disease (LMD) in Non-ST-elevation acute coronary syndrome.

METHODS

Literature searching was performed in the online database, and a systematic review was conducted based on the searched results. Meaningful STE in lead aVR was summarized and analyzed for odds ratio (OR) and 95% confidence intervals (95% CI).

RESULTS

Twenty-seven articles were included for final data analysis. Compared with STE < 0.05, STE ≥ 0.05 mV was associated with a higher incidence rate of LMD (OR = 6.64, 95% CI: 4.80 ~ 9.17), and the degree of STE in lead aVR was significantly associated with LMD. Myocardial infarction was more likely to occur in patients with STE ≥ 0.05 mV than in patients with STE < 0.05 mV (OR = 3.12, 95% CI: 1.73 ~ 5.62).

CONCLUSIONS

The STE in lead aVR and the degree of STE are independent predictors in diagnosing LMD or myocardial infarction.

Prolonged P wave peak time is associated with the severity of coronary artery disease in patients with non-ST segment elevation myocardial infarction

BACKGROUND

Multi-vessel coronary artery disease (CAD) is associated with worse outcome in non-ST segment elevation myocardial infarction (NSTEMI) patients. Depending on the severity of CAD, there may be prolongation of atrial depolarization time as a result of left ventricular dysfunction and atrial ischemia. Therefore, we aimed to study whether the severity of CAD can be predicted with the P wave peak time (PWPT) in the electrocardiography (ECG) obtained during the diagnosis in NSTEMI patients.

METHOD

A total of 162 patients were included. The coronary angiography records of all patients were analyzed and SYNTAX scores were calculated. Patients were divided into two groups, according to CAD severity. In addition to well-known P wave parameters, PWPT, defined as the time from the beginning of the P wave to its peak, was measured in the leads D_II and V₁.

RESULTS

The PWPTs in the leads D_II and V₁ were significantly longer in the group with severe CAD (71 ± 13 vs. 61 ± 12, p < 0.001, 63 ± 24 vs. 53 ± 18, p = 0.024, respectively). PWPT was found to be an independent predictor of severe CAD and the best cut-off value of PWPT in the lead D_II was 69.6 ms with sensitivity of 58.3% and specificity of 78.9%.

CONCLUSION

Our findings show that prolonged PWPT, which is a parameter easily obtainable from the ECG, is associated with severe CAD. Recognition of NSTEMI patients with severe CAD at the time of diagnosis before performing coronary angiography may be important for the planning of treatment.

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.

Lead aVR is a predictor for mortality in heart failure with preserved ejection fraction

Background

Normally, lead augmented vector right (aVR) has a negative T wave polarity (TaVR) in the electrocardiography (ECG). Positive TaVR and ST segment deviation in lead aVR (STaVR) have negative effects on mortality in heart failure with reduced ejection fraction patients.

Aim

Our aim was to investigate the relationship between lead aVR changes and mortality in heart failure with preserved ejection fraction (HFpEF) patients.

Methods

We retrospectively examined 249 patients in 2011–2015 years (mean age 70.8 ± 11.9 years and follow-up period 38.3 ± 9.6 months). ECG, echocardiographic, and laboratory findings were recorded and compared in the study. Existence of positive TaVR, STaVR, and quantitative TaVR values were recorded and the absolute numerical values of TaVR and STaVR were recorded from the 12-lead surface ECG (T/STaVR ratio or vice versa).

Results

The patients were divided into two groups: living (171) and deceased (78). Age, systolic blood pressure, left atrial diameter, QRS duration, positive TaVR frequency, STaVR, absolute value of TaVR, and ratio were significantly higher in the deceased group. Age (OR: 1.106), STaVR (OR: 2.349), TaVR (OR: 1.612), and T/STaVR ratio (OR: 5.156) were determined as independent predictors for mortality.

Conclusions

ST segment and T wave polarity changes in lead aVR closely associated with mortality in patients with HFpEF.

T wave positivity in lead aVR is associated with mortality in patients with cardiac resynchronization therapy

PURPOSE

Positive T wave polarity in lead aVR (TPaVR) is associated with a poor prognostic indicator in patients with heart failure reduce ejection fraction (HFrEF). Our aim was to investigate the relationship between positive TPaVR and mortality in patients with cardiac resynchronization therapy defibrillator (CRT-D).

METHODS

We included retrospectively 224 HFrEF patients with CRT-D in sinus rhythm. Laboratory, electrocardiographic (ECG), and echocardiographic data were recorded. T wave polarity was measured in lead DI, DII, and aVR from surface ECG.

RESULTS

The patients were divided as living and deceased. They followed for 2.5 ± 0.9 years. Thirty-three patients (14.7%) died. Six patients (18.2%) were TPaVR positive before CRT-D and this number increased to 22 (66.6%) after CRT-D in the deceased group. Pulse (p = 0.049), hyperlipidemia (p = 0.022), and NT-proBNP levels were higher in the deceased group (p = 0.001). TPaVR before CRT-D (p < 0.001) and TPaVR after CRT-D (p < 0.001) were significantly positive in the deceased group. Positive TPaVR after CRT-D was the only independent predictor for mortality in binominal logistic regression analysis (OR 1.211, 95% CI 1.105-1.328, p < 0.001).

CONCLUSIONS

In CRT-D patients, a positive TPaVR in surface ECG may be a strong mortality indicator.

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.

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.

The association between electrocardiographic R wave peak time and coronary artery disease severity in patients with non-ST segment elevation myocardial infarction and unstable angina pectoris

BACKGROUND

We aimed to evaluate possible association between QRS duration (QRSD), R wave peak time (RWPT), and coronary artery disease severity identified using the SYNTAX score (SS) in patients with unstable angina pectoris (USAP) or non-ST segment elevation myocardial infarction (NSTEMI).

METHOD

A total of 176 USAP/NSTEMI patients were enrolled in the study.

RESULTS

The high SS group (>22, n:45) patients had a higher prevalence of diabetes mellitus (DM); presence of ST segment depression ≥0.5 mm and 1 mm; ST segment elevation in the AVR lead (AVRSTE); longer QRSD and RWPT; and lower left ventricular ejection fraction (LVEF) than the low SS group (≤22, n: 131). The LVEF, AVRSTE, and RWPT (OR: 1.035, 95% CI: 1.003-1.067; p = 0.030) were independent predictors of high SS.

CONCLUSION

The present study demonstrated that RWPT and AVRSTE could be used as predictors of high SS.

Exercise test predictors of severe coronary artery disease: Role of ST-segment elevation in lead aVR

BACKGROUND

The role of exercise stress test (EST)-induced ST-segment elevation (STE) in electrocardiographic lead aVR in predicting severe coronary artery disease (CAD) is controversial.

HYPOTHESIS

Assessment of lead aVR during EST can be helpful to identify patients with severe CAD.

METHODS

We performed maximal EST in 200 patients undergoing coronary angiography for suspect of CAD. Four angiographic findings of severe CAD were considered: (1) left main (LM) disease; (2) LM or equivalent LM (LM/EQLM) disease; (3) LM or proximal left anterior descending (LAD) artery (LM/proxLAD) disease; and (4) LM or 3-vessel (LM/3V) disease.

RESULTS

LM, LM/EQLM, LM/proxLAD, and LM/3V disease were shown in 6 (3%), 13 (6.5%), 33 (16.5%), and 27 (13.5%) patients, respectively. EST-induced STE in aVR occurred in 41 patients (20.5%). ST-segment depression (STD) in ≥5 leads was the only predictor of LM stenosis (odds ratio [OR]: 6.18, 95% confidence interval [CI]: 1.19-32.2, P = 0.03) and the most significant variable associated with LM/proxLAD stenosis (OR: 4.73, 95% CI: 2.0-11.2, P = 0.0001); maximal STD ≥3 mm was the most significant variable associated with LM/EQLM (OR: 7.58, 95% CI: 2.31-24.9, P = 0.001) and LM/3V (OR: 3.86, 95% CI: 1.47-10.1, P = 0.006) CAD. EST-induced STE in aVR was associated with LM/proxLAD disease only (OR: 3.23, 95% CI: 1.44-7.24, P = 0.004). At multivariate analysis, STD in ≥5 leads was the only independent predictor of LM/proxLAD disease (OR: 3.99, 95% CI: 1.58-10.1, P = 0.003).

CONCLUSIONS

EST-induced STE in lead aVR does not significantly increase the prediction of severe CAD compared with severity and extension of STD as assessed in the other electrocardiographic leads.

Chicken or the egg: ST elevation in lead aVR or SYNTAX score

Background:

ST-segment elevation in lead aVR (STEaVR) anticipates left main and/or three-vessel disease (LM/3VD) in patients with acute coronary syndromes. STEaVR is generally reciprocal to and accompanied by ST-segment depression (STD) in the precordial leads. SYNTAX score (SS) is an angiographic scoring system and is widely used to evaluate the severity and complexity of coronary artery disease. The purpose of our study was to assess the relationship between STEaVR and SS.

Methods:

We performed a retrospective analysis of 117 patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). Electrocardiograms at presentation were reviewed, especially for ST-segment elevation of ≥ 0.05 mV in lead aVR and STD of ≥ 0.05 mV in more than two contiguous leads. All lesions causing ≥ 50% stenosis in a coronary artery with a diameter of ≥ 1.5 mm were included in the SS calculation. SS was divided into two groups: ≥ 23: high, < 23: low.

Results:

Among the 117 patients, 80 (68.4%) had STEaVR and 37 (31.6%) did not. Patients with STEaVR had a higher SS and higher rate of LM/3VD (85 vs 67.6%, p < 0.001; 86.2 vs 72.9%, p = 0.03, respectively) than those without STEaVR. On multivariate analysis, STEaVR [odds ratio (OR) 1.85; 95% confidence interval (CI): 1.20–3.97, p = 0.03] and STD in leads V₁–V₄ (OR 2.14; 95% CI: 1.46–4.23, p = 0.002) were independent predictors of a high SS.

Conclusion:

This study demonstrated that STEaVR was an independent predictor of a high SS.

Association Between Preinfarction Angina and Angiographic Findings in Non-ST-Segment Elevation Myocardial Infarction

BACKGROUND

The association between preinfarction angina and angiographic findings has not been elucidated in patients with non-ST-segment elevation myocardial infarction (NSTEMI).

HYPOTHESIS

Patients with preinfarction angina have favorable angiographic findings.

METHODS

This retrospective study analyzed 481 patients who underwent coronary angiography within 5 days of presenting NSTEMI. Preinfarction angina was defined as experiencing ≥1 chest-pain episode within 7 days prior to admission. Infarct size was measured as the peak cardiac troponin I (cTnI) level, and large myocardial infarction (MI) was defined as a peak cTnI level >85th percentile value in the study population. Infarct-related artery (IRA) patency was defined as Thrombolysis In Myocardial Infarction grade 2 or 3 flow. Clinical and angiographic characteristics and in-hospital mortality were compared between patients with and without preinfarction angina.

RESULTS

Among 481 patients, 200 (42%) had preinfarction angina. Preinfarction angina was associated with smaller infarct size, indicated by lower peak cTnI levels (P = 0.006) and lower incidence of large MI (P = 0.02), and IRA patency (P = 0.03). There was no significant difference in in-hospital mortality. On multivariate analysis, both preinfarction angina (odds ratio: 0.53, 95% confidence interval: 0.29-0.94, P = 0.03) and IRA patency (odds ratio: 0.30, 95% confidence interval: 0.17-0.52, P < 0.001) were independent negative predictors of large MI.

CONCLUSION

Our study demonstrates that preinfarction angina is a predictor of smaller infarct size and infarct-related artery patency in NSTEMI patients, suggesting that NSTEMI patients presenting without preinfarction angina are at increased risk of developing a large MI.