Abstract 8928: ST-Segment Elevation in Lead aVR is the Strongest Predictor of Severe Left Main or 3-Vessel Disease in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome
In non-ST-segment elevation acute coronary syndrome (NSTE-ACS), early identification of patients who require urgent coronary artery bypass graft surgery (CABG), such as those with severe left main or 3-vessel disease (LM/3VD), is crucial in determining the early use of clopidogrel, which can increase the risk of surgical bleeding.
Methods: We studied 572 patients with NSTE-ACS who underwent coronary angiography during hospitalization. ST-segment deviations were measured on admission ECG. Troponin T, brain natriuretic peptide (BNP), and high-sensitivity C-reactive protein (hsCRP) were also measured on admission. Severe LM/3VD was defined as ≥75% stenosis of LM and/or 3VD with ≥90% stenosis in ≥2 proximal lesions of the left anterior descending coronary artery and other major epicardial artery. Patients were divided into the 3 groups according to angiographic findings: G-A, no LM/3VD (n=460); G-B, LM/3VD but not severe LM/3VD (n=57); and G-C, severe LM/3VD (n=55).
Results: Age, sex, and coronary risk factors except for diabetes mellitus were similar among the 3 groups. In G-A, G-B, and G-C, the rates of diabetes mellitus were 30%, 51%, and 55% Killip class ≥2 was 6%, 16%, and 31% positive troponin T was 29%, 49%, and 60% the levels of BNP were 168±281, 337±472, and 398±373 pg/ml; hsCRP was 0.265±0.392, 0.353±0.307, and 0.962±1.130 mg/dl; the degrees of summed ST-segment depression in all leads except aVR were 2.6±3.6, 6.7±5.1, and 10.5±7.3 mm; ST-segment elevation in lead aVR (ST↑aVR) was 0.1±0.3, 0.6±0.5, and 1.3±0.5 mm; the rates of urgent CABG were 2%, 4%, and 60% and death or (re)infarction at 30 days was 3%, 7%, and 13%, respectively (all p<0.05). In multivariate analysis, the degree of ST↑aVR was the strongest predictor of severe LM/3VD (OR 29.1, 95% CI 9.54–49.8, p<0.001), followed by positive troponin T (OR 1.27, 95% CI 1.10–2.78, p=0.044). ST↑aVR of ≥1.0 mm best identified severe LM/3VD. ST↑aVR of ≥1.0 mm and positive troponin T identified severe LM/3VD with sensitivities of 80% and 60% (p=0.02), specificities of 93% and 69% (p<0.001), and predictive accuracies of 92% and 68% (p<0.001), respectively.
Conclusions: Our findings suggest that admission ST-segment elevation in lead aVR of ≥1.0 mm strongly predicts severe LM/3VD in patients with NSTE-ACS.
- © 2010 by American Heart Association, Inc.