Relationship of ST elevation in lead aVR with angiographic findings and outcome in non–ST elevation acute coronary syndromes

Yan, Andrew T.; Yan, Raymond T.; Kennelly, Brian M.; Anderson, Frederick A.; Budaj, Andrzej; López-Sendón, José; Brieger, David; Allegrone, Jeanna; Steg, Gabriel; Goodman, Shaun G.; for the GRACE Investigators,

doi:10.1016/j.ahj.2007.03.037

« Previous Next »American Heart Journal
Volume 154, Issue 1 , Pages 71-78, July 2007

Relationship of ST elevation in lead aVR with angiographic findings and outcome in non–ST elevation acute coronary syndromes

Andrew T. Yan, MD
- Division of Cardiology, St. Michael's Hospital, University of Toronto, and Canadian Heart Research Centre, Toronto, Ontario, Canada
Raymond T. Yan, MD
- Division of Cardiology, St. Michael's Hospital, University of Toronto, and Canadian Heart Research Centre, Toronto, Ontario, Canada
Brian M. Kennelly, MB, ChB, PhD
- Hoag Memorial Hospital, Newport Beach, CA
Frederick A. Anderson Jr, PhD
- University of Massachusetts Medical School, Worcester, MA
Andrzej Budaj, MD, PhD
- Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
José López-Sendón, MD
- Cardiology Department, Hospital Universitario La Paz, Madrid, Spain
David Brieger, MBBS, PhD
- Coronary Care Unit, Concord Hospital, Sydney, Australia
Jeanna Allegrone, BA, PhD
- University of Massachusetts Medical School, Worcester, MA
Gabriel Steg, MD
- Hôpital Bichat, Paris, France
Shaun G. Goodman, MD, MSc
- Division of Cardiology, St. Michael's Hospital, University of Toronto, and Canadian Heart Research Centre, Toronto, Ontario, Canada
- Reprint requests: Shaun G. Goodman, MD, MSc, St. Michael's Hospital, Division of Cardiology, 30 Bond Street, Room 6-034 Queen, Toronto, Ontario, Canada M5B 1W8.
for the GRACE Investigators

Received 29 October 2006; accepted 15 March 2007. published online 01 May 2007.

Background

Limited data suggest that ST elevation (ST↑) in aVR is associated with higher mortality and more extensive coronary artery disease in the setting of non-ST↑ acute coronary syndromes (ACS).

Methods

In the prospective Global Registry of Acute Coronary Events (GRACE) electrocardiographic substudy, the admission electrocardiograms were analyzed by a blinded core laboratory. We performed multivariable analysis to determine (1) the independent prognostic significance of ST↑ in aVR and (2) its association with significant (≥50% stenosis) left main or 3-vessel disease (LM/3-vd).

Results

Among 5064 patients with non-ST↑ ACS, 4696 had no ST↑ in aVR, 292 (5.8%) had minor (0.5-1 mm) ST↑ in aVR, and 76 (1.5%) had major (>1 mm) ST↑ in aVR; their in-hospital mortality rates were 4.2%, 6.2%, and 7.9%, respectively (P for trend =.03). At 6 months follow-up, the cumulative mortality rates were 7.6%, 12.7%, and 18.3%, respectively (log-rank P for trend <.001). However, minor and major ST↑ in aVR were not independent predictors of in-hospital or 6-month death after adjusting for other validated prognosticators in the GRACE risk model. Of the 2416 patients without prior coronary bypass surgery who underwent cardiac catheterization, the prevalence of LM/3-vd was 26.1%, 36.2%, and 55.9% for the groups with no, minor, and major ST↑ in aVR, respectively (P for trend <.001). After adjusting for other clinical characteristics, major ST↑ in aVR remained an independent predictor of LM/3-vd (adjusted odds ratio, 2.68; 95% confidence interval, 1.29-5.58; P = .008).

Conclusion

ST↑ in aVR is less prevalent than reported in previous smaller studies. Although it is associated with higher unadjusted in-hospital and 6-month mortality, it does not provide incremental prognostic value beyond comprehensive risk stratification using the validated GRACE risk model. However, ST↑ greater than 1 mm in aVR may be useful in the early identification of LM/3-vd in ACS patients with ST depression.