Abstract 3214: ST-Segment Elevation Resolution in Lead aVR: A Strong Predictor of Adverse Outcomes in Patients With Non-ST-segment Elevation Acute Coronary Syndrome
Background ST-segment elevation in lead aVR (ST↑aVR) on admission ECG is considered a useful predictor of left-main or 3-vessel disease (LMT/3VD) and poor outcomes in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). However, the prognostic value of the change in ST↑aVR after admission remains unclear.
Methods We studied 367 patients with NSTE-ACS who had chest discomfort within 48 h before admission. Patients with left ventricular hypertrophy were excluded. ECGs were recorded on admission and 6 h after admission. ST-segment deviation of ≤0.5 mm was considered significant. A reduction of >50% in ST↑aVR between the value on admission and that 6 h later was defined as ST resolution. Patients were classified into the 3 groups according to ECG findings: group A, no ST↑aVR on admission (n=275); group B, ST↑aVR on admission with ST resolution (n=50); and group C, ST↑aVR on admission without ST resolution (n=42). Troponin T, high-sensitivity C-reactive protein (hs-CRP), and B-type natriuretic peptide (BNP) were measured on admission. Coronary angiography was performed a mean of 3 days after admission.
Results There were no significant differences in sex or coronary risk factors among the 3 groups. In groups A, B, and C, age was 66±11, 69±8, and 72±10 years (p<0.001); hs-CRP was 0.534±1.351, 0.617±1.121, 0.960±2.049 mg/dl (p=0.12); BNP was 167±310, 195±208, 360±287 pg/ml (p=0.03); the rate of ST-segment depression in other leads on admission ECG was 62%, 100%, and 100% (p<0.001); positive troponin T was 39%, 58%, and 64% (p<0.001); multivessel disease was 26%, 66%, and 95% (p<0.001); LMT/3VD was 7%, 32%, and 74% (p<0.001); and the composite endpoint of death, (re)infarction, or urgent revascularization within 30 days after admission was 6%, 18%, and 71% (p<0.001), respectively. Multivariate analysis showed that no ST resolution (OR 26.7, 95% CI 12.1 to 99.8, p<0.001) was the strongest predictor of adverse events at 30 days, followed by positive troponin T (OR 3.19, 95% CI 1.27 to 7.99, p=0.01).
Conclusions In patients with NSTE-ACS, persistent ST-segment elevation in lead aVR 6 h after admission is the strongest predictor of 30-day adverse outcomes. ST-segment analysis of lead aVR after admission can facilitate risk stratification in NSTE-ACS.