title: Short- and long-term prognostic significance of ST-segment elevation in lead aVR in patients with non-ST-segment elevation acute coronary syndrome.
abstract: We sought to evaluate the prognostic significance of ST-segment elevation (STE) in lead aVR in unselected patients with non-STE acute coronary syndrome (NSTE-ACS). We enrolled 1,042 consecutive patients with NSTE-ACS. Patients were divided into 5 groups according to the following electrocardiographic (ECG) patterns on admission: (1) normal electrocardiogram or no significant ST-T changes, (2) inverted T waves, (3) isolated ST deviation (ST depression [STD] without STE in lead aVR or transient STE), (4) STD plus STE in lead aVR, and (5) ECG confounders (pacing, right or left bundle branch block). The main angiographic end point was left main coronary artery (LM) disease as the culprit artery. Clinical end points were in-hospital and 1-year cardiovascular death defined as the composite of cardiac death, fatal stroke, and fatal bleeding. Prevalence of STD plus STE in lead aVR was 13.4%. Rates of culprit LM disease and in-hospital cardiovascular death were 8.1% and 3.8%, respectively. On multivariable analysis, patients with STD plus STE in lead aVR (group 4) showed an increased risk of culprit LM disease (odds ratio 4.72, 95% confidence interval [CI] 2.31 to 9.64, p <0.001) and in-hospital cardiovascular mortality (odds ratio 5.58, 95% CI 2.35 to 13.24, p <0.001) compared to patients without any ST deviation (pooled groups 1, 2, and 5), whereas patients with isolated ST deviation (group 3) did not. At 1-year follow-up 127 patients (12.2%) died from cardiovascular causes. On multivariable analysis, STD plus STE in lead aVR was a stronger independent predictor of cardiovascular death (hazard ratio 2.29, 95% CI 1.44 to 3.64, p <0.001) than isolated ST deviation (hazard ratio 1.52, 95% CI 0.98 to 2.36, p = 0.06). In conclusion, STD plus STE in lead aVR is associated with high-risk coronary lesions and predicts in-hospital and 1-year cardiovascular deaths in patients with NSTE-ACS. Therefore, this promptly available ECG pattern could be useful to improve risk stratification and management of patients with NSTE-ACS.
authors.affiliation: Institute of Cardiology, St. Orsola/Malpighi Hospital, Bologna University, Bologna, Italy. neviotaglieri@hotmail.it
authors.forename: Nevio
authors.initials: N
authors.lastname: Taglieri
authors.forename: Antonio
authors.initials: A
authors.lastname: Marzocchi
authors.forename: Francesco
authors.initials: F
authors.lastname: Saia
authors.forename: Cinzia
authors.initials: C
authors.lastname: Marrozzini
authors.forename: Tullio
authors.initials: T
authors.lastname: Palmerini
authors.forename: Paolo
authors.initials: P
authors.lastname: Ortolani
authors.forename: Laura
authors.initials: L
authors.lastname: Cinti
authors.forename: Stefania
authors.initials: S
authors.lastname: Rosmini
authors.forename: Fabio
authors.initials: F
authors.lastname: Vagnarelli
authors.forename: Laura
authors.initials: L
authors.lastname: Alessi
authors.forename: Caterina
authors.initials: C
authors.lastname: Villani
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Scaramuzzino
authors.forename: Ilaria
authors.initials: I
authors.lastname: Gallelli
authors.forename: Giovanni
authors.initials: G
authors.lastname: Melandri
authors.forename: Angelo
authors.initials: A
authors.lastname: Branzi
authors.forename: Claudio
authors.initials: C
authors.lastname: Rapezzi
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D000368:Aged; D002423:Cause of Death / Q000639:trends; D017023:Coronary Angiography; D003937:Diagnosis, Differential; D018450:Disease Progression; D042241:Early Diagnosis; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate / Q000639:trends; D013997:Time Factors