The prognostic value of T wave amplitude in lead aVR in males

Prognostic Value of T-wave Positivity in Lead aVR in COVID-19 Pneumonia

OBJECTIVE

T-wave positivity in the lead aVR is a marker of ventricular repolarization abnormality and provides information on short- and long-term cardiovascular mortality in heart failure patients, those with anterior myocardial infarction, and patients who underwent hemodialysis for various reasons. The aim of this study was to investigate the relationship between T-wave positivity in the lead aVR on superficial electrocardiogram and mortality from COVID-19 pneumonia.

METHODS

This study retrospectively included 130 patients who were diagnosed with COVID-19 and treated as an outpatient or in the thoracic diseases ward in a single center between January 2021 and June 2021. All patients included in the study had clinical and radiological features and signs of COVID-19 pneumonia. The COVID-19 diagnosis of all patients was confirmed by polymerase chain reaction detected from an oropharyngeal swab.

RESULTS

A total of 130 patients were included in this study. Patients were divided into two groups: survived and deceased. There were 55 patients (mean age: 64.76-14.93 years, 58.18 male, 41.12% female) in the survived group and 75 patients (mean age: 65-15 years, 58.67 male, 41.33% female) in the deceased group. The univariate and multivariate regression analyses showed that positive transcatheter aortic valve replacement (OR 5.151; 95%CI 1.001-26.504; p=0.0012), lactate dehydrogenase (OR 1.006; 95%CI 1.001-1.010; p=0.012), and d-dimer (OR 1.436; 95%CI 1.115-1.848; p=0.005) were independent risk factors for mortality.

CONCLUSION

A positive transcatheter aortic valve replacement is useful in risk stratification for mortality from COVID-19 pneumonia.

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.

A New Method for Detecting Myocardial Ischemia Based on ECG T-Wave Area Curve (TWAC)

In recent years, coronary heart disease (CHD) has become one of the main diseases that endanger human health, with a high mortality and disability rate. Myocardial ischemia (MI) is the main symptom in the development of CHD. Continuous and severe myocardial ischemia will lead to myocardial infarction. The clinical manifestations of MI are mainly the changes of ST-T segment of ECG, that is, ST segment and T wave. Nearly one third of patients with CHD, however, has no obvious ECG changes. In this paper, a new method for detecting MI based on the T-wave area curve (TWAC) was proposed. Through observation and analysis of clinical data, it was found that there exist significant correlation between the morphology of TWAC and MI. The TWAC morphology of normal subject is smooth and gentle, while the TWAC morphology of patients with coronary stenosis is mostly jagged, and the curve becomes more severe with more severe stenosis. The preliminary test results show that the sensitivity, specificity, and accuracy of the proposed method for detecting MI are 84.3, 83.6, and 84%, respectively. This study shows that the TWAC based approach may be an effective method for detecting MI, especially for the CHD patients with no obvious ECG changes.

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.

Noninvasive long-term ECG monitoring vs. loop recorder implantation for the atrial fibrillation management

OBJECTIVE

The objective of the study was to estimate the efficacy of a noninvasive ambulatory ECG monitoring (NIAM) in comparison with implantable loop recorder (ILR) in patients with atrial fibrillation (AF).

METHODS

Thirty-two patients 58 [47; 73] years of age with AF were included in the study. Patients were randomized into two groups: in group I (n = 15), "Reveal XT" ILR was used for invasive ECG monitoring up to 3 months; in group II (n = 17), "Spyder" device was used for NIAM up to 14 days.

RESULTS

In both groups, at least one AF episode was detected during 14 days of monitoring. The overall count of AF episodes was 25 in NIAM group and 28 in ILR group. The mean time between AF start and its registration by a physician was 8 hr in NIAM group and 20 hr in ILR group (p = .005). The diagnostic value parameters of NIAM were as follows: sensitivity-80.1%, specificity-73.1%; positive predictive value-74.1%; and negative predictive value-79.2%. The same parameters in ILR group were comparable with NIAM: sensitivity-78.6%; specificity-69%; positive predictive value-71%; and negative predictive value-77%. At the same time, continued monitoring with ILR for longer than two weeks did not lead to a significant change in the sensitivity and specificity of the method.

CONCLUSION

In patients with paroxysmal AF, the diagnostic value of both NIAM and ILR is comparable. An increase in the duration of ECG monitoring for longer than two weeks does not provide additional diagnostic information.

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.

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.

Association Between Depression, Anxiety, and Antidepressant Use With T-Wave Amplitude and QT-Interval

Objectives: Cardiac repolarization may be affected by psychiatric disorders and/or antidepressant use, but evidence for this is inconclusive. This study examined the relationship between depressive and anxiety disorder and use of antidepressants with T-wave amplitude (TWA) and QT-interval.

Methods: Data was obtained from the Netherlands Study of Depression and Anxiety (n = 1,383). Depression/anxiety was diagnosed with the DSM-IV based Composite International Diagnostic Interview. The use of tricyclic antidepressants (TCAs), selective serotonin and noradrenalin reuptake inhibitors (SNRIs), and selective serotonin reuptake inhibitors (SSRIs) was established. T-wave amplitude and QT-interval corrected for heart rate (QTc) were obtained from an ECG measured in a type II axis configuration.

Results: Compared to controls, persons with depression or anxiety disorders did not show a significantly different TWA (p = 0.58; Cohen's d = 0.046) or QTc (p = 0.48; Cohen's d = −0.057). In spite of known sympathomimetic effects, TCA use (p = 0.26; Cohen's d = −0.162) and SNRI use (p = 0.70; Cohen's d = −0.055) were not significantly associated with a lower TWA. TCA use (p = 0.12; Cohen's d = 0.225) and SNRI use (p = 0.11; Cohen's d = 0.227) were also not significantly associated with a prolonged QTc.

Conclusion: We did not find evidence that either depressive/anxiety disorder or antidepressant use is associated with abnormalities in TWA or QTc. Earlier found sympathomimetic effects of TCAs and SNRIs are not evident in these measures of cardiac repolarization.

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.

Impact of T wave amplitude in lead aVR on predicting cardiac events in ischemic and nonischemic cardiomyopathy patients with an implantable cardioverter defibrillator

BACKGROUND

T wave amplitudes during ventricular repolarization in the lead aVR (TAaVR) are shown to be associated with adverse cardiac events in patients with several cardiovascular diseases, such as postmyocardial infarction. However, the utility of TAaVR has not been previously evaluated in patients with cardiomyopathy who have received implantable cardioverter defibrillators (ICD). Patients with ischemic or nonischemic cardiomyopathy (ICM or NICM, respectively) and who received an ICD may experience worsening of their condition due to the introduction of electric shock during treatment. This study aimed to investigate the utility of TAaVR in the prediction of cardiac events in ICM or NICM patients with ICD.

METHODS

Ninety-three consecutive ICM or NICM patients with ICD were retrospectively analyzed (median age: 64 years; male: 77.4%; ICD for secondary prevention: 76.3%; NICM: 64.5%). The median follow-up period was 31 months. The primary endpoint was defined as composite cardiac events, including cardiac death, major ventricular arrhythmic events (MVAE), or hospitalization due to heart failure (HHF).

RESULTS

Multivariate Cox regression analysis demonstrated that less negative TAaVR (-0.1 mV ≤ TAaVR <0 mV and 0 mV ≤ TAaVR) was independently associated with the primary endpoint (HR: 3.75; 95% confidence interval [CI]: 1.09-23.7; p = .04). Kaplan-Meier curve also revealed that the event free survival rate in the less negative TAaVR group was significantly lower than that in the normal TAaVR group (<-0.1 mV) (p < .01).

CONCLUSIONS

TAaVR is useful in risk stratification for cardiac events in ICM or NICM patients with ICD.

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.

Positive T wave in lead aVR as an independent predictor for 1-year major adverse cardiac events in patients with first anterior wall ST-segment elevation myocardial infarction

BACKGROUND

Positive T wave in lead aVR has been shown to predict an adverse in-hospital outcome in patients with anterior wall ST-segment elevation myocardial infarction (STEMI). However, the prognostic value of positive T wave in lead aVR on a long-term outcome has not been fully explored.

METHODS

We performed a retrospective analysis of 190 consecutive patients with first anterior wall STEMI who underwent an emergent coronary angiogram. Patients were divided into those with positive T wave > 0 mV and those with negative T wave ≦ 0 mV in lead aVR. Baseline and angiographic characteristics, and in-hospital revascularization procedures were recorded. In addition, in-hospital and 1-year major adverse cardiac events (MACE) including death, recurrent myocardial infarction, and target vessel revascularization were recorded.

RESULTS

Among 190 patients, 37 patients (19%) had positive T wave and 153 patients (81%) had negative T wave in lead aVR. Patients with positive T wave had higher rate of left main disease defined as stenosis ≥50% (11% vs. 2%, p = .028) than those with negative T wave. Patients with positive T wave had higher rate of 1-year MACE (38% vs. 13%, p < .001) driven by higher all-cause mortality (27% vs. 5%, p < .001). Positive T wave was an independent predictor for 1-year MACE (OR 2.74; 95% CI 1.04-7.15; p = .04).

CONCLUSION

Positive T wave in lead aVR was an independent predictor for 1-year MACE in patients with first anterior wall STEMI.

Twenty-eight genetic loci associated with ST-T-wave amplitudes of the electrocardiogram

The ST-segment and adjacent T-wave (ST-T wave) amplitudes of the electrocardiogram are quantitative characteristics of cardiac repolarization. Repolarization abnormalities have been linked to ventricular arrhythmias and sudden cardiac death. We performed the first genome-wide association meta-analysis of ST-T-wave amplitudes in up to 37 977 individuals identifying 71 robust genotype–phenotype associations clustered within 28 independent loci. Fifty-four genes were prioritized as candidates underlying the phenotypes, including genes with established roles in the cardiac repolarization phase (SCN5A/SCN10A, KCND3, KCNB1, NOS1AP and HEY2) and others with as yet undefined cardiac function. These associations may provide insights in the spatiotemporal contribution of genetic variation influencing cardiac repolarization and provide novel leads for future functional follow-up.

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.

The classical versus the Cabrera presentation system for resting electrocardiography: Impact on recognition and understanding of clinically important electrocardiographic changes

The classical system for presentation of the 12-lead electrocardiogram (ECG) reflects the electrical activity of the heart as viewed in the transverse plane by 6 leads with a single anatomically ordered sequence, V1-V6; but in the frontal plane by 6 leads with dual sequences, I, II, and III, and aVR, aVL, and aVF. However, there is also a single anatomically ordered sequence of leads, called the Cabrera display that presents the six frontal plane leads in their anatomically ordered sequence of: aVL, I, -aVR, II, aVF, and III. Although it has been recognized that the Cabrera system has clinical diagnostic advantages compared to the classical display, it is currently only used in Sweden. The primary explanation of why the Cabrera system has not been adopted internationally has been that analog ECG recorders had technical limitations. Currently, however, the classical system is most often seen as a historical remnant that prevails because of conservatism within the cardiology community.

T-wave inversion and mortality risk

OBJECTIVE

To investigate the predictive value of T-wave inversion (TWI) on routine electrocardiogram (ECG) for mortality in the general population with various risk groups in a prospective population-based follow-up study. Subjects. ECGs of a random population-based sample of 1814 men aged 42-60 years without coronary heart disease (CHD) at baseline.

RESULTS

During an average follow-up of 21 years, 685 deaths occurred. Of these deaths 174 were due to CHD and 278 to cardiovascular disease (CVD). There were 57 subjects with TWI. After adjusting for age, TWI was associated with an increased CHD mortality (relative risk (RR) 4.10, 95% CI 2.26-7.41), CVD mortality (RR 3.47, 95% CI 2.09-5.78), and all-cause mortality (RR 2.07, 95% CI 1.37-3.12). After further adjustment for conventional risk factors, TWI remained statistically significant, predicting CHD mortality (RR 2.62, 95% CI 1.57-4.36), CVD mortality (RR 2.18, 95% CI 1.40-3.38), and all-cause mortality (RR 1.41, 95% CI 1.00-2.01), respectively.

CONCLUSION

TWI is a strong predictor for CHD, CVD, and all-cause mortality in the general population. The respective risks of CHD and CVD among men with TWI were also increased among men with high blood pressure, LDL cholesterol, and obesity.

Justification of an introductory electrocardiogram teaching mnemonic by demonstration of its prognostic value

OBJECTIVES

With diminishing time afforded to electrocardiography in the medical curriculum, we have found Sibbitt's simple mnemonic, the Diagonal Line Lead Rule, for a pattern recognition approach to 12-lead electrocardiogram (ECG) interpretation to be appreciated by students. However, it still lacks universal acceptance because its clinical utility has not been documented. The study objective was to demonstrate the clinical utility of the Diagonal Line Lead ECG Teaching Rule.

METHODS

After excluding ECGs of high-risk patients with Wolff-Parkinson-White syndrome and QRS durations greater than 120 ms, the initial ECGs of the remaining 43,798 patients were scored according to the Diagonal Line Lead Rule. A total of 45,497 patients from the Veterans Affairs Palo Alto Healthcare System were referred for a routine initial resting ECG from 1987 to 1999. We determined cardiovascular mortality with 8 years of follow-up.

RESULTS

In patients with normal QRS duration, diagnostic Q-wave or T-wave inversions isolated to the diagonal line leads showed no increased risk of cardiovascular death. Q-wave or T-wave inversion in any other lead was significantly associated with cardiovascular death with an age-adjusted Cox hazard of 2.6 (confidence interval, 2.4-2.8; P < .0001) and an annual cardiovascular mortality rate of 3.0%. Leads V4-V6, I, and aVL were especially significant predictors of cardiovascular death, with a Cox hazard greater than 3.

CONCLUSIONS

Our analysis demonstrates the prognostic power and clinical utility of a simple mnemonic for 12-lead ECG interpretation that can facilitate ECG teaching and interpretation.

Usefulness of electrocardiographic QRS/T angles with versus without bundle branch blocks to predict heart failure (from the Atherosclerosis Risk in Communities Study)

Repolarization abnormalities in the setting of bundle branch blocks (BBB) are generally ignored. We used Cox regression models to determine hazard ratios (HRs) with 95% confidence intervals (CIs) for incident heart failure (HF) associated with wide spatial and frontal QRS/T angle (upper twenty-fifth percentile of each) in men and women with and without BBB. This analysis included 14,478 participants (54.6% women, 26.4% blacks, 377 [2.6%] with BBB) from the Atherosclerosis Risk in Communities Study who were free of HF at baseline. Using No-BBB with normal spatial QRS/T angle as the reference group, the risk for HF in multivariable adjusted models was increased 51% for No-BBB with wide spatial QRS/T angle (HR 1.51, 95% CI 1.37 to 1.66), 48% for BBB with normal spatial QRS/T angle (HR 1.48, 95% CI 1.17 to 1.88), and the risk for incident HF was increased more than threefold for BBB with wide spatial QRS/T angle (HR 3.37, 95% CI 2.47 to 4.60). The results were consistent across subgroups by gender. Similar results were observed for the frontal plane QRS/T angle. In the pooled BBB group excluding right BBB, a positive T wave in lead aVR and heart rate 70 bpm and higher were also potent predictors of incident HF similar to the QRS/T angles. In conclusion, both BBB and wide QRS/T angles are predictive of HF, and concomitant presence of both carries a much higher risk than for either predictor alone. These findings suggest that repolarization abnormalities in the setting of BBB should not be considered benign or an expected consequence of BBB.

Electrocardiographic repolarization-related variables as predictors of coronary heart disease death in the women's health initiative study

BACKGROUND

We evaluated 25 repolarization-related ECG variables for the risk of coronary heart disease (CHD) death in 52 994 postmenopausal women from the Women's Health Initiative study.

METHODS AND RESULTS

Hazard ratios from Cox regression were computed for subgroups of women with and without cardiovascular disease (CVD). During the average follow-up of 16.9 years, 941 CHD deaths occurred. Based on electrophysiological considerations, 2 sets of ECG variables with low correlations were considered as candidates for independent predictors of CHD death: Set 1, Ѳ(Tp|Tref), the spatial angle between T peak (Tp) and normal T reference (Tref) vectors; Ѳ(Tinit|Tterm), the angle between the initial and terminal T vectors; STJ depression in V6 and rate-adjusted QTp interval (QTpa); and Set 2, TaVR and TV1 amplitudes, heart rate, and QRS duration. Strong independent predictors with over 2-fold increased risk for CHD death in women with and without CVD were Ѳ(Tp|Tref) >42° from Set 1 and TaVR amplitude >-100 μV from Set 2. The risk for these CHD death predictors remained significant after multivariable adjustment for demographic/clinical factors. Other significant predictors for CHD death in fully adjusted risk models were Ѳ(Tinit|Tterm) >30°, TV1 >175 μV, and QRS duration >100 ms.

CONCLUSIONS

Ѳ(Tp|Tref) angle and TaVR amplitude are associated with CHD mortality in postmenopausal women. The use of these measures to identify high-risk women for further diagnostic evaluation or more intense preventive intervention warrants further study.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00000611.

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.

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

Electrocardiographic lead aVR is often ignored in clinical practice. The aim of this study was to investigate whether ST-T wave amplitude in lead aVR predicts cardiovascular (CV) mortality and if this variable adds value to a traditional risk prediction model. A total of 7,928 participants enrolled in the National Health and Nutrition Examination Survey (NHANES) III with electrocardiographic data available were included. Each participant had 13.5 ± 3.8 years of follow-up. The study sample was stratified according to ST-segment amplitude and T-wave amplitude in lead aVR. ST-segment elevation (>8 μV) in lead aVR was predictive of CV mortality in the multivariate analysis when not accounting for T-wave amplitude. The finding lost significance after including T-wave amplitude in the model. A positive T wave in lead aVR (>0 mV) was the strongest multivariate predictor of CV mortality (hazard ratio 3.37, p <0.01). The addition of T-wave amplitude in lead aVR to the Framingham risk score led to a net reclassification improvement of 2.7% of subjects with CV events and 2.3% of subjects with no events (p <0.01). Furthermore, in the intermediate-risk category, 20.0% of the subjects in the CV event group and 9.1% of subjects in the no-event group were appropriately reclassified. The absolute integrated discrimination improvement was 0.012 (p <0.01), and the relative integrated discrimination improvement was 11%. In conclusion, T-wave amplitude in lead aVR independently predicts CV mortality in a cross-sectional United States population. Adding T-wave abnormalities in lead aVR to the Framingham risk score improves model discrimination and calibration with better reclassification of intermediate-risk subjects.

Electrocardiographic predictors of coronary heart disease and sudden cardiac deaths in men and women free from cardiovascular disease in the Atherosclerosis Risk in Communities study

Background

We evaluated predictors of coronary heart disease (CHD) death and sudden cardiac death (SCD) in the Atherosclerosis Risk in Communities (ARIC) study.

Methods and Results

The study population included 13 621 men and women 45 to 65 years of age free from manifest cardiovascular disease at entry. Hazard ratios from Cox regression with 95% confidence intervals were computed for 18 dichotomized repolarization‐related ECG variables. The average follow‐up was 14 years. Independent predictors of CHD death in men were TaVR‐ and rate‐adjusted QTend (QT_ea), with a 2‐fold increased risk for both, and spatial angles between mean QRS and T vectors and between Tpeak (T_p) and normal R reference vectors [θ(R_m|T_m) and θ(T_p|T_ref), respectively], with a >1.5‐fold increased risk for both. In women, independent predictors of the risk of CHD death were θ(R_m|T_m), with a 2‐fold increased risk for θ(R_m|T_m), and θ(T_p|T_ref), with a 1.7‐fold increased risk. Independent predictors of SCD in men were θ(T_p|T_ref) and QT_ea, with a 2‐fold increased risk, and θ(T_init|T_term), with a 1.6‐fold increased risk. In women, θ(T_init|T_term) was an independent predictor of SCD, with a >3‐fold increased risk, and θ(R_m|T_m) and TV1 were >2‐fold for both.

Conclusions

θ(R_m|T_m) and θ(T_p|T_ref), reflecting different aspects of ventricular repolarization, were independent predictors of CHD death and SCD, and TaVR and TV1 were also independent predictors. The risk levels for independent predictors for both CHD death and SCD were stronger in women than in men, and QT_ea was a significant predictor in men but not in women.

Prognostic significance of T-wave amplitude in lead aVR on the admission electrocardiography in patients with anterior wall ST-elevation myocardial infarction treated by primary percutaneous intervention

BACKGROUND

T-wave positivity in aVR lead patients with heart failure and anterior wall old ST-segment elevation myocardial infarction (STEMI) are shown to have a higher frequency of cardiovascular mortality, although the effects on patients with STEMI treated with primary percutaneous coronary intervention (PCI) has not been investigated. In this study, we sought to determine the prognostic value of T wave in lead aVR on admission electrocardiography (ECG) for in-hospital mortality in patients with anterior wall STEMI treated with primary PCI.

METHODS

After exclusion, 169 consecutive patients with anterior wall STEMI (mean age: 55 ± 12.9 years; 145 men) undergoing primary PCI were prospectively enrolled in this study. Patients were classified as a T-wave positive (n = 53, group 1) or T-wave negative (n = 116, group 2) in aVR based upon the admission ECG. All patients were evaluated with respect to clinical features, primary PCI findings, and in-hospital clinical results.

RESULTS

T-wave positive patients who received primary PCI were older, multivessel disease was significantly more frequent and the duration of the patient's hospital stay was longer than T-wave negative patients. In-hospital mortality tended to be higher in the group 1 when compared with group 2 (7.5% vs 1.7% respectively, P = 0.05). After adjusting the baseline characteristics, positive T wave remained an independent predictor of in hospital mortality (odds ratio: 4.41; 95% confidence interval 1.2-22.1, P = 0.05).

CONCLUSIONS

T-wave positivity in lead aVR among patients with an anterior wall STEMI treated with primary PCI is associated with an increase in hospital cardiovascular mortality.

Electrocardiographic QT interval and mortality: a meta-analysis

BACKGROUND

Extremely abnormal prolongation of the electrocardiographic QT interval is associated with malignant ventricular arrhythmias and sudden cardiac death. However, the implications of variations in QT-interval length within normal limits for mortality in the general population are still unclear.

METHODS

We performed a meta-analysis to investigate the relation of QT interval with mortality endpoints. Inverse-variance weighted random-effects models were used to summarize the relative risks across studies. Twenty-three observational studies were included.

RESULTS

The pooled relative risk estimates comparing the highest with the lowest categories of QT-interval length were 1.35 (95% confidence interval = 1.24-1.46) for total mortality, 1.51 (1.29-1.78) for cardiovascular mortality, 1.71 (1.36-2.15) for coronary heart disease mortality, and 1.44 (1.01-2.04) for sudden cardiac death. A 50 milliseconds increase in QT interval was associated with a relative risk of 1.20 (1.15-1.26) for total mortality, 1.29 (1.15-1.46) for cardiovascular mortality, 1.49 (1.25-1.76) for coronary heart disease mortality, and 1.24 (0.97-1.60) for sudden cardiac death.

CONCLUSIONS

We found consistent associations between prolonged QT interval and increased risk of total, cardiovascular, coronary, and sudden cardiac death. QT-interval length is a determinant of mortality in the general population.

Relation of positive T wave in lead aVR to risk of cardiovascular mortality

We examined the prevalence and prognostic impact of a positive T wave in lead aVR (aVRT+) on a standard electrocardiogram in the general population. Data were collected from a large nationally representative (random sample) health examination survey conducted in Finland from 2000 through 2001. The survey consisted of 6,354 subjects (2,876 men and 3,478 women) ≥30 years who participated in the field health examination including standard electrocardiographic (ECG) recording at rest. The prevalence of aVRT+ (defined as positive or isoelectric T wave in lead aVR) was 2.2%. During the median follow-up of 98.5 months (interquartile range 96.6 to 99.6), there were 214 (3.5%) cardiovascular (CV) deaths. In Cox regression analysis after adjustment for age and gender, relative risks for CV and total mortalities associated with aVRT+ were 3.24 (95% confidence interval [CI] 2.32 to 4.54, p <0.001) and 1.91 (95% CI 1.47 to 2.49, p <0.001), respectively. In the fully adjusted model controlling for other risk factors, CV morbidity, and ECG findings, the relative risk for CV mortality for aVRT+ was 2.94 (95% CI 2.07 to 4.18, p <0.001). In conclusion, aVRT+, an easily recognized ECG finding, predicts risk for CV mortality in the general population. This finding could aid in screening for risk of total and CV mortalities.

Prognostic significance of T-wave amplitude in lead aVR in heart failure patients with narrow QRS complexes

BACKGROUND

Prolonged duration of the QRS complex is a prognostic marker in patients with heart failure (HF), whereas electrocadiographic markers in HF with narrow QRS complex remain unclear. We evaluated the prognostic value of the T-wave amplitude in lead aVR in HF patients with narrow QRS complexes.

METHODS

We examined 331 patients who were admitted to our hospital for worsening HF (68 ± 15 years, mean ± standard deviation) from January 2000 to October 2004 who had sinus rhythm and QRS complex <120 ms. The patients were categorized into three groups according to the peak T-wave amplitude from baseline in lead aVR: negative (<-0.1 mV; n = 209, 63%), flat (-0.1-0.1 mV; n = 64, 19%), and positive (>0.1 mV; n = 58, 18%).

RESULTS

During a mean follow-up of 33 months, 113 (34%) patients had all-cause death, the primary end point. After adjusting for clinical covariates, flat T wave (hazard ratio [HR] 1.86, 95% confidence interval [CI] 1.42-2.46), and positive T wave (HR 6.76, 95% CI 3.92-11.8) were independent predictors of mortality, when negative T wave was considered a reference.

CONCLUSIONS

As the peak T-wave amplitude in lead aVR becomes less negative, there was a progressive increase in mortality. The T wave in lead aVR provides prognostic information for risk stratification in HF patients with narrow QRS complexes.

Upright T waves in lead aVR are associated with cardiac death or hospitalization for heart failure in patients with a prior myocardial infarction

The aim of the present study was to clarify the prognostic significance of upright T waves (amplitude > 0 mV) in lead aVR in patients with a prior myocardial infarction (MI). We retrospectively examined 167 patients with a prior MI. The primary end point was cardiac death or hospitalization for heart failure. During a follow-up period of 6.5 ± 2.8 years, 34 patients developed the primary end point. A Kaplan-Meier analysis showed a lower primary event-free rate in patients with upright T waves in lead aVR than in those with nonupright T waves in lead aVR (P = 0.001). Univariate Cox proportional hazards regression analyses showed that age, gender, chronic kidney disease, anterior wall MI, upright T waves in lead aVR, left ventricular ejection fraction, loop diuretic use, and spironolactone use were significantly associated with the primary end point. A multivariate Cox proportional hazards regression analysis selected age [hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.05-1.16, P < 0.001], upright T waves in lead aVR (HR 3.10, 95% CI 1.23-7.82, P = 0.017), and loop diuretic use (HR 4.61, 95% CI 1.55-13.67, P = 0.006) as independent predictors of the primary end point. In conclusion, the presence of upright T waves in lead aVR is an independent predictor of cardiac death or hospitalization for heart failure in patients with a prior MI. The analysis of T-wave amplitude in lead aVR provides useful prognostic information in patients with a prior MI.

Associations of positive T wave in lead aVR with hemodynamic, coronary, and left ventricular angiographic findings in anterior wall old myocardial infarction

BACKGROUND

No information is available on the clinical significance of a positive T wave in lead aVR in myocardial infarction (MI). Accordingly, in the present study, we sought to clarify the associations of the positive T wave in lead aVR with hemodynamic, coronary angiographic, and left ventriculographic findings in anterior wall old MI.

METHODS

We examined 122 patients with anterior wall old MI who underwent diagnostic or follow-up cardiac catheterization including coronary angiography and left ventriculography. The patients were classified into the following 2 groups: patients with a positive (≥ 1mm) T wave in lead aVR (n=20, group A) and those without (n=102, group B).

RESULTS

Group A had higher pulmonary arterial, pulmonary capillary wedge, and left ventricular (LV) end-diastolic pressures and a lower cardiac index than group B. The prevalence of a long left anterior descending coronary artery (LAD) was higher in group A than in group B (60% vs 30.4%, p=0.01), and none of group A patients had an LAD that did not reach the apex. Group A had a lower LV ejection fraction than group B (36.4 ± 11.6% vs 48.4 ± 12.7%, p<0.001).

CONCLUSIONS

The positive T wave in lead aVR is related to severely reduced cardiac function, with an LAD wrapping the apex, in anterior wall old MI. Further studies are needed to clarify whether the positive T wave in lead aVR is associated with an adverse outcome in patients with anterior wall old MI.

Clinical utility of aVR-The neglected electrocardiographic lead

BACKGROUND

Several studies suggest that electrocardiographers tend to neglect lead aVR during the reading of electrocardiograms (ECGs). Our objective was to provide a systematic review of the most important diagnostic and prognostic uses of lead aVR.

METHODS

We performed a thorough review of the literature about the lead aVR using PubMed, MEDLINE and the archives of the University at Buffalo libraries.

RESULTS

We found that lead aVR may provide important additional information in the diagnosis of coronary artery disease. It may provide a clue to the location of a lesion as well as the possibility of three vessel disease during an acute coronary syndrome. Lead aVR was found useful in the locus of arrhythmias and in differentiation of narrow and wide QRS complex tachycardias. It provides useful prognostic information for patients with the Brugada syndrome and tricyclic antidepressant toxicity. Lead aVR provides alternative criteria for the electrocardiographic diagnosis of left ventricular hypertrophy and left anterior fascicular block.

CONCLUSION

Lead aVR provides very important additional diagnostic and prognostic information in multiple cardiac conditions and can be used either alone or in conjunction with other electrocardiographic leads.