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aVR ST elevation: an important but neglected sign in ST elevation acute myocardial infarction

Cheuk-Kit Wong, Wanzhen Gao, Ralph A.H. Stewart, Jocelyne Benatar, John K. French, Philip E.G. Aylward, Harvey D. White
DOI: http://dx.doi.org/10.1093/eurheartj/ehq161 First published online: 31 May 2010

Abstract

Aim This study evaluated the prognostic implications of aVR ST elevation during ST elevation acute myocardial infarction (AMI).

Methods and results The Hirulog and Early Reperfusion/Occlusion-2 study randomized 17 073 patients with acute ST elevation AMI within 6 h of symptom onset to receive either bivalirudin or heparin, in addition to streptokinase and aspirin. The treatments had no effect on the primary endpoint of 30-day mortality. Electrocardiographic recordings were performed at randomization and at 60 min after commencing streptokinase. aVR ST elevation ≥1 mm was associated with higher 30-day mortality in 15 315 patients with normal intraventricular conduction regardless of AMI location (14.7% vs. 11.2% for anterior AMI, P = 0.0045 and 16.0% vs. 6.4% for inferior AMI, P < 0.0001). After adjusting for summed ST elevation and ST depression in other leads, associations with higher mortality were found with aVR ST elevation of ≥1.5 mm for anterior [odds ratio 1.69 (95% CI 1.16 to 2.45)] and of ≥1 mm for inferior AMI [odds ratio 2.41 (95% CI 1.76 to 3.30)]. There was a significant interaction between aVR ST elevation and infarct location. Thirty-day mortality was similar with anterior and inferior AMI when aVR ST elevation was present (11.5% vs. 13.2%, respectively, P = 0.51 with 1 mm and 23.5% vs. 22.5% respectively, P = 0.84 with ≥ 1.5 mm ST elevation). After fibrinolytic therapy, resolution of ST elevation in aVR to <1 mm was associated with lower mortality, while new ST elevation ≥1 mm was associated with higher mortality.

Conclusion aVR ST elevation is an important adverse prognostic sign in AMI.

  • Electrocardiography
  • Mortality
  • Myocardial infarction
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