title: Diagnostic and Prognostic Value of Lead aVR During Exercise Testing in Patients Suspected of Having Myocardial Ischemia.
abstract: We aimed to assess the diagnostic and prognostic value of ST-segment deviation in aVR, a lead often ignored in clinical practice, during exercise testing and to compare it to the most widely used criterion of ST-segment depression in V5. We enrolled 1,596 patients with suspected myocardial ischemia referred for nuclear perfusion imaging undergoing bicycle stress testing. ST-segment amplitudes in leads aVR and V5were automatically measured. The presence of inducible myocardial ischemia was the diagnostic end point and adjudicated based on nuclear perfusion imaging and coronary angiography. Major adverse cardiac events (MACE) during 2 years of follow-up including death, acute myocardial infarction, and coronary revascularization were the prognostic end point. Exercise-induced myocardial ischemia was detected in 470 patients (29%). Median ST amplitudes for leads aVR and V5differed significantly among patients with and without ischemia (p <0.01). The diagnostic accuracy of ST changes for myocardial ischemia as quantified by the area under the receiver operating characteristic curve was highest 2 minutes into recovery and similar in aVR and V5(0.62, 95% confidence interval CI 0.60 to 0.65 vs 0.60, 95% confidence interval 0.58 to 0.63, p = 0.08 for comparison). In multivariate analysis, ST changes in lead aVR, but not lead V5, contributed independent diagnostic information on top of clinical parameters and manual electrocardiographic interpretation. Within 2 years of follow-up, MACE occurred in 33% of patients with ST elevations in aVR and in 16% without (p <0.001). In conclusion, ST elevation in lead aVR during exercise testing indicates inducible myocardial ischemia independently of ST depressions in lead V5and clinical factors and also predicts MACE during follow-up.
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Max
authors.initials: M
authors.lastname: Wagener
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; Institute of Medical Engineering, Lucerne University of Applied Sciences and Arts, Horw, Switzerland.
authors.forename: Roger
authors.initials: R
authors.lastname: Abächerli
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Ursina
authors.initials: U
authors.lastname: Honegger
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Schaerli
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Gil
authors.initials: G
authors.lastname: Prêtre
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland; Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.
authors.forename: Raphael
authors.initials: R
authors.lastname: Twerenbold
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Christian
authors.initials: C
authors.lastname: Puelacher
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Germaine
authors.initials: G
authors.lastname: Sunier
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Philipp
authors.initials: P
authors.lastname: Reddiess
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Maria
authors.initials: M
authors.lastname: Rubini Gimenez
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Karin
authors.initials: K
authors.lastname: Wildi
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Jasper
authors.initials: J
authors.lastname: Boeddinghaus
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Thomas
authors.initials: T
authors.lastname: Nestelberger
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Patrick
authors.initials: P
authors.lastname: Badertscher
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Zaid
authors.initials: Z
authors.lastname: Sabti
authors.affiliation: Signal Processing, Schiller AG, Baar, Switzerland.
authors.forename: Ramun
authors.initials: R
authors.lastname: Schmid
authors.affiliation: Signal Processing, Schiller AG, Baar, Switzerland.
authors.forename: Remo
authors.initials: R
authors.lastname: Leber
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Dayana Flores
authors.initials: DF
authors.lastname: Widmer
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Samyut
authors.initials: S
authors.lastname: Shrestha
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Ivo
authors.initials: I
authors.lastname: Strebel
authors.affiliation: University of Basel, Basel, Switzerland; Division of Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
authors.forename: Damian
authors.initials: D
authors.lastname: Wild
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Stefan
authors.initials: S
authors.lastname: Osswald
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Michael
authors.initials: M
authors.lastname: Zellweger
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors.forename: Christian
authors.initials: C
authors.lastname: Mueller
authors.affiliation: Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland. Electronic address: tobias.reichlin@usb.ch.
authors.forename: Tobias
authors.initials: T
authors.lastname: Reichlin
mesh_terms: D000368:Aged; D017023:Coronary Angiography; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000503:physiopathology*; D011379:Prognosis; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon
chemical_list: D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi