title: The forgotten lead: does aVR ST-deviation add insight into the outcomes of ST-elevation myocardial infarction patients?
abstract: BACKGROUND
  Lead aVR ST-segment deviation has been associated with increased mortality in ST-elevation myocardial infarction patients treated with fibrinolysis. However, its prognostic value in a contemporaneous population undergoing primary percutaneous coronary intervention is unknown.
  
  
  RESULTS
  A core laboratory examined the 12-lead baseline electrocardiogram in 5,683 patients presenting within 6 hours of symptom onset in the APEX-AMI trial, and readers were blinded to study treatment and clinical outcomes. aVR ST-deviation was significantly associated with 90-day death when compared with patients with no aVR ST-deviation (aVR ST-depression [ST-D] 5%, aVR ST-elevation [ST-E] 10.2%, no ST-deviation [N] aVR 3.8%, P < .001). After multivariable adjustment, aVR ST-E was strongly associated with 90-day death in inferior myocardial infarction (MI) (adjusted hazard ratio [HR] 5.87, 95% CI 2.09-16.5), whereas aVR ST-D was associated with excess mortality in noninferior MI (1.53, 1.06-2.22; P [interaction] < .001). aVR ST-E was also significantly associated with the presence of left main coronary (N aVR 1.8%, aVR ST-E 7.7%, P ≤ .001) and multivessel coronary disease (N aVR 41.3%, aVR ST-E 53.3%, P ≤ .001).
  
  
  CONCLUSIONS
  Lead aVR ST-deviation is common, occurring in one-third of all ST-elevation myocardial infarction patients and independently associated with increased 90-day death. Myocardial infarction location modulates the prognostic significance of aVR ST-deviation such that lead aVR ST-E in inferior MI and ST-D in noninferior MI represent 2 high-risk groups. There was also more frequent advanced coronary disease in patients with aVR ST-E.
authors.affiliation: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Aws
authors.initials: A
authors.lastname: Alherbish
authors.forename: Cynthia M
authors.initials: CM
authors.lastname: Westerhout
authors.forename: Yuling
authors.initials: Y
authors.lastname: Fu
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Granger
authors.forename: Galen
authors.initials: G
authors.lastname: Wagner
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
mesh_terms: D000368:Aged; D003324:Coronary Artery Disease / Q000473:pathology / Q000503:physiopathology; D004562:Electrocardiography / Q000379:methods*; D004566:Electrodes; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D062645:Percutaneous Coronary Intervention; D011379:Prognosis; D016032:Randomized Controlled Trials as Topic