Admission ST-segment elevation in lead aVR as the factor improving complex risk stratification in acute coronary syndromes

This study aimed to analyze the prognostic value of the presence of ST elevation in lead aVR [aVR(+)] in initial standard electrocardiogram (ECG) performed on admission in combination with clinical variables and Thrombolysis in Myocardial Infarction (TIMI) risk score for unstable angina/non–ST-elevation myocardial infarction (UA/NSTEMI). In 205 consecutive patients with UA/NSTEMI, we retrospectively evaluated admission ECG for aVR(+) of more than 0.5 mm. With the use of multivariate analysis, admission aVR(+) was found to be a strong and independent predictor of 30-day mortality. Mortality also increased with the severity of aVR(+): 2.2%, 10.8%, 13.8%, 22.2%, 50% (P value for trend <.0001). In prespecified low-risk groups by clinical factors, those with aVR(+) had higher death rates than those without aVR(+): 16.1% vs 2.2% (P = .04), 13.9% vs 1.1% (P = .001), 12.4% vs 1.1% (P = .002), 9.6% vs 1.2% (P = .02), and 6.7% vs 0% (P = .05) for patients with negative troponin, heart rate of 110 beats per minute or less, systolic blood pressure greater than 90 mm Hg, Killip I class on admission, and age 70 years or younger, respectively. Patients with aVR(+) compared to patients without aVR(+) had higher death rates in the low- and intermediate-risk groups by TIMI risk score. Our findings suggest that aVR(+) has significant prognostic value in patients with UA/NSTEMI and may provide an additional prognostic value to the conventional cardiovascular risk factor, particularly in patients in the low-risk and intermediate-risk groups.