ST-segment depression in lead aVR predicts predischarge left ventricular dysfunction in patients with reperfused anterior acute myocardial infarction with anterolateral ST-segment elevation

doi:10.1067/mhj.2001.116073

American Heart Journal

Volume 142, Issue 1, July 2001, Pages 51-57

https://doi.org/10.1067/mhj.2001.116073 Get rights and content

Abstract

Background Patients with an anterolateral acute myocardial infarction (AMI) have a worse prognosis, and those with additional inferolateral wall involvement might be higher risk because of more extensive area at risk. Lead –aVR obtained by inversion of images in lead aVR has been reported to provide useful information for inferolateral lesion. Methods We examined the relation between ST-segment deviation in lead aVR on admission electrocardiogram (ECG) and left ventricular function in 105 patients with an anterolateral AMI undergoing successful reperfusion ≤6 hours after onset. Patients were classified according to ST-segment deviation in lead aVR on admission ECG: group A, 23 patients with ST elevation of ≥0.5 mm; group B, 47 patients without ST deviation; and group C, 35 patients with ST depression of ≥0.5 mm. Results There were no differences among the 3 groups in age, sex, or site of the culprit lesion. In groups A, B, and C, the peak creatine kinase level was 3661 ± 1428, 4440 ± 1889, and 6959 ± 2712 mU/mL, and the left ventricular ejection fraction (LVEF) measured by predischarge left ventriculography was 54% ± 9%, 48% ± 7%, and 37% ± 9%, respectively(P <.01). During hospitalization, congestive heart failure occurred more frequently in group C than in groups A or B (P <.05). ST-segment depression in lead aVR had a higher predictive accuracy than other ECG findings in identifying patients with predischarge LVEF ≤35%. Conclusions We conclude that in patients with an anterolateral AMI, ST-segment depression in lead aVR on admission ECG is useful for predicting larger infarct and left ventricular dysfunction despite successful reperfusion. (Am Heart J 2001;142:51-7.)

Section snippets

Patients

Between December 1990 and May 1999, 105 patients (91 men and 14 women, mean age 58 years, range 29 to 81 years) with AMI who fulfilled the following criteria were admitted to our coronary care unit within 6 hours from symptom onset: (1) typical chest pain lasting for at least 30 minutes, (2) STsegment elevation of ≥2.0 mm in >2 contiguous precordial leads as well as ST-segment elevation of ≥1.0 mm in leads I, aVL, or both, (3) a subsequent increase in serum creatine kinase levels to more than

Patient characteristics

Patients were divided into 3 groups according to ST-segment deviation in lead aVR on admission ECG: 23 patients with ST-segment elevation of ≥0.5 mm in lead aVR (group A, Figure 1,A ), 47 without ST-segment deviation (group B, Figure 1,B ), and 35 with ST-segment depression of ≥0.5 mm (group C, Figure 1,C ).

. Representative ECGs of the 3 groupsA, Group A, culprit lesion, Seg 6. Time from symptom onset to reperfusion, 3.3 hours. LVEF, 49% at discharge. B, Group B, culprit lesion, Seg 6. Time from

Discussion

In patients with anterior AMI, high ST-segment elevation in precordial and lateral leads or high inferior ST-segment depression on admission ECG has been shown to be correlated with a large infarct size and high hospital mortality.10, 11 Because these studies have examined the relationship between ST-segment deviation excluding lead aVR and infarct size in patients with anterior AMI, whether ST-segment deviation in lead aVR is related to infarct size remains unknown. Our study demonstrated that

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ST-segment deviation in lead aVR on admission is not associated with left ventricular function at predischarge in first anterior wall ST-segment elevation acute myocardial infarction
2011, American Journal of Cardiology
Citation Excerpt :
The results of the present study are in disagreement with those of Kosuge et al.9 The exact reasons for this discrepancy are unclear, but the differences in methods and patient selection might have led to this discrepancy. The study of Kosuge et al9 included patients with successfully reperfused first AA-STEMI who had ST-segment elevation in precordial and lateral leads (I and aVL) on admission and who had TIMI grade 3 flow on predischarge coronary angiography, and they analyzed ST-segment levels at 20 ms after the end of the QRS complex. In contrast, we included patients with AA-STEMI who underwent admission coronary procedures and predischarge coronary angiography together with left ventriculography, and we analyzed ST-segment levels at the J point, which is recommended by the American Heart Association, American College of Cardiology Foundation, and Heart Rhythm Society.14
Previous studies have shown that the analysis of ST-segment deviation in lead aVR on admission provides useful information on angiographic coronary anatomy and risk stratification in acute coronary syndromes. However, the association between ST-segment deviation in lead aVR on admission and left ventricular (LV) function has not been fully investigated in anterior wall acute ST-segment elevation myocardial infarction. In this study, 237 patients with first anterior wall acute ST-segment elevation myocardial infarction were examined. The patients were divided into the following 3 groups according to ST-segment deviation in lead aVR on admission: 85 with ST-segment elevation ≥0.5 mm (group A), 106 without ST-segment deviation (group B), and 46 with ST-segment depression ≥0.5 mm (group C). LV ejection fractions at predischarge were compared among the 3 groups. Among the 3 groups, there were significant differences in the prevalences of proximal left anterior descending coronary artery (LAD) occlusion (group A 75.3%, group B 56.6%, group C 45.7%, p = 0.002), long LAD (group A 27.1%, group B 31.1%, group C 56.5%, p = 0.002), and good collaterals to the LAD (group A 40.0%, group B 25.4%, group C 17.4%, p = 0.01). LV ejection fractions at predischarge did not differ among the 3 groups (group A 56.4 ± 12.5%, group B 56.9 ± 12.7%, group C 53.3 ± 12.2%, p = 0.26). On a multiple regression analysis, establishment of Thrombolysis In Myocardial Infarction grade 3 flow, proximal LAD occlusion, and long LAD were associated with the LV ejection fraction at predischarge. In conclusion, ST-segment deviation in lead aVR on admission is not associated with LV function at predischarge in first anterior wall acute ST-segment elevation myocardial infarction.
Significance of a prominent Q wave in lead negative aVR (-aVR) in acute anterior myocardial infarction
2010, Journal of Electrocardiology
Citation Excerpt :
The negative aVR (−aVR) lead fills the gap, and the orderly lead disposition (aVL, I, −aVR, II, aVF, and III) provides a comprehensive view of the frontal plane.1-5 Increasing attention has been recently paid to the analysis of ST-segment shift in lead aVR (or −aVR) in the diagnosis and risk stratification of acute coronary syndrome.6-15 However, systematical studies concerning a Q wave in lead −aVR in acute myocardial infarction (AMI) have not so far been undertaken.
The aim of this study was to clarify the significance of a Q wave in lead negative aVR (−aVR) in anterior wall acute myocardial infarction (AMI).
Eighty-seven patients with a first anterior wall AMI were classified into 2 groups according to the presence (n = 17, group A) or absence (n = 70, group B) of a prominent Q wave (duration ≥20 milliseconds) in lead −aVR at predischarge. Group A had a higher prevalence of a long left anterior descending coronary artery (LAD), a lower left ventricular ejection fraction, and more reduced regional wall motion in the apical and inferior regions than group B. None of group A patients had an LAD that did not reach the apex.
A prominent Q wave in lead −aVR in anterior wall AMI is related to severe regional wall motion abnormality in the apical and inferior regions, with an LAD wrapping around the apex.
Determinants of ST-segment level in lead aVR in anterior wall acute myocardial infarction with ST-segment elevation
2009, Journal of Electrocardiology
Citation Excerpt :
Most electrocardiographers have considered lead aVR as just giving reciprocal information from the left lateral side, that being already covered by leads aVL, II, V5, and V6.1-3 Recently, an analysis of ST-segment level in lead aVR has been reported to be useful in the identification of the site of coronary artery occlusion during AMI4-6 and in the risk stratification in patients with various conditions of acute coronary syndrome, including anterior wall AMI (AAMI) with ST-segment elevation (STE),7,8 inferior wall AMI,9 or non-STE acute coronary syndrome.10,11 However, determinants for the ST-segment level in lead aVR have not yet been fully investigated in STE-AMI.
This study aimed to clarify the determinants of ST-segment level in lead aVR in anterior wall acute myocardial infarction (AAMI).
We analyzed ST-segment levels in all 12 leads on admission and emergency coronary angiographic findings in 261 patients with a first AAMI with ST-segment elevation. The length of the left anterior descending coronary artery (LAD) was classified as follows: short = not reaching the apex; medium = perfusing less than 25% of the inferior wall; long = perfusing 25% or more of the inferior wall.
The ST-segment level in lead aVR correlated significantly with the ST-segment levels in leads I, II, III, aVF, V₁, and V_3-6, especially with those in leads II and V₆ (r = −0.63, P < .001; r = −0.61, P < .001; respectively). Patients with a proximal LAD occlusion had a greater ST-segment level in lead aVR than those with a distal LAD occlusion (P < .001). Patients with a long LAD had a lower ST-segment level than those with a short or medium LAD (P < .05).
The ST-segment levels, especially in leads II and V₆, the site of the LAD occlusion, and the length of the LAD affect the ST-segment level in lead aVR in ST-segment elevation AAMI.
Value of the 12-lead electrocardiogram to define the level of obstruction in acute anterior wall myocardial infarction: Correlation to coronary angiography and clinical outcome in the DANAMI-2 trial
2009, International Journal of Cardiology
Citation Excerpt :
In these cases extensive subendocardial ischaemia induced by severely elevated left ventricular end-diastolic pressure and diastolic dysfunction has been proposed. Kosuge et al reported that the proximity of the culprit lesion in the LAD was similar in patients with ST-elevation, without ST-segment deviation or with ST-depression in aVR [19]. However, they only included patients with ST-elevation ≥ 2 mm in > 2 contiguous precordial leads and ST-elevation ≥ 1 mm in leads I, aVL or both possibly resulting in a selection bias favoring the ECG pattern of proximal LAD occlusion.
Acute anterior myocardial infarction (MI) caused by proximal occlusion of the left anterior descending coronary artery (LAD), is associated with unfavourable outcome and should be recognized by simple noninvasive methods like the 12-lead electrocardiogram (ECG).
In a prospective post-hoc DANAMI-2 substudy we compared two pre-specified ECG patterns to determine the level of LAD occlusion. The ECG findings were correlated to coronary angiography from the acute phase. The impact on clinical outcome of ECG and angiographic signs of proximal versus distal LAD occlusion was studied.
In 146 patients without confounding factors on the ECG, either ST-elevation ≥ 0.5 mm in lead aVL or any ST-elevation in lead aVR in association with precordial ST-segment elevation in at least two contiguous leads (including V₂, V₃ or V₄) had a sensitivity of 94%, specificity of 49%, positive predictive value of 85% and negative predictive value of 71% to predict a proximal LAD lesion. Surprisingly, ECG or angiographic signs of lesion proximality were not associated with worse outcome at 30 day or 2.7 year follow-up.
The site of occlusion in the LAD could be reliably predicted by 12-lead ECG in patients with acute anterior MI. The prognostic significance of the level of occlusion in the LAD in the modern era of acute ST-elevation MI treatment should be reassessed.
Twelve-lead electrocardiogram: The advantages of an orderly frontal lead display including lead -aVR
2004, Journal of Electrocardiology
Background: It is possible that efforts in ECG review by both young experienced clinicians are currently discouraged—and risk to be completely dismissed—by the conventional (ie, disorderly) display of the frontal plane leads, with lead aVR at −150°. Methods: We reviewed studies on the usefulness of leads aVR and −aVR as well as on the history of the frontal leads in electrocardiography. Results: Lead aVR and particularly, lead −aVR, provide useful information when systematically analyzed. In addition, if lead −aVR is examined in its anatomically logical sequence, ie, aVL, I, −aVR, II, aVF, and III, the frontal plane of the 12-lead ECG is more easily understood. This “panoramic” or “orderly” display is in common use in countries such as Sweden, but it is rarely seen in the United States. Conclusions: ECG interpretation would be enhanced by displaying the limb leads in an orderly arrangement that starts with lead aVL and ends with lead III, and many ECG changes would be ideally displayed by a lead −aVR at 30°.
The prognostic effect of ST-elevation in lead aVR on coronary artery disease, and outcome in acute coronary syndrome patients: a systematic review and meta-analysis
2022, European Journal of Medical Research

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^☆: Reprint requests: Kazuo Kimura, MD, Department of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan. E-mail: [email protected]

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Acute Ischemic Heart DiseaseST-segment depression in lead aVR predicts predischarge left ventricular dysfunction in patients with reperfused anterior acute myocardial infarction with anterolateral ST-segment elevation☆

Abstract

Section snippets

Patients

Patient characteristics

Discussion

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction

Circulation

Severity of residual stenosis of infarct-related lesion and left ventricular function after single-vessel anterior wall myocardial infarction: implication of ST-segment elevation in lead aVL of the admission electrocardiograms

Clin Cardiol

Improving the ECG classification of inferior and lateral myocardial infarction by inversion of lead aVR

Heart

Acute Ischemic Heart Disease
ST-segment depression in lead aVR predicts predischarge left ventricular dysfunction in patients with reperfused anterior acute myocardial infarction with anterolateral ST-segment elevation☆