Abstract
Background: In patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), ST-segment depression (STD) has been shown to be associated with poor outcomes; however, lead aVR is not considered. Lead aVR is referred to as a “cavity lead,” and ST-segment elevation in this lead (STE-aVR) might reflect global subendocardial ischemia. Methods: We studied 818 patients with NSTE-ACS who underwent coronary angiography during hospitalization. ST-segment deviation was measured on admission ECG, and it was considered present if ≥ 0.5 mm. Troponin T (TnT), hemoglobin (Hb), estimated glomerular filtration rate (eGFR), high-sensitivity C-reactive protein (hsCRP), brain natriuretic peptide (BNP), and TIMI risk score were also measured on admission. Results: STD in 11 leads except aVR was observed in 568 patients. Among these patients, 225 patients had STE-aVR. In patients with no STD (n=250), isolated STD (n=343), and STD plus STE-aVR (n=225), age was 63±10, 67±11, and 70±11 years; the rates of diabetes mellitus were 25%, 32%, and 50%; Killip class ≥2 was 2%, 6%, and 27%; positive TnT was 22%, 34%, and 49%; the levels of Hb were 13.8±1.7, 13.9±1.9, and 12.7±2.2 g/dl; eGFR was 69.1±22.8, 65.8±24.7, and 56.8±27.5 ml/min/1.73m 2 ; hsCRP was 0.310±1.480, 0.499±1.249, and 0.899±1.820 mg/dl; BNP was 90±203, 200±359, and 431±575 pg/ml; TIMI risk core was 1.9±1.2, 3.1±1.3, and 3.6±1.2; the frequencies of left main/3-vessel disease were 4.0%, 8.5%, and 56.9%; and in-hospital adverse events (death, [re]infarction, or urgent revascularization) were 5.2%, 8.7%, and 31.6%, respectively (all p<0.01). Multivariate analysis showed that STD plus STE-aVR (OR 3.56, 95%CI 1.13-7.99, p<0.01) was the strongest predictor of in-hospital adverse events, followed by positive TnT (OR 1.33, 95%CI 1.03-2.99, p=0.048), but isolated STD was not. Conclusions: In patients with NSTE-ACS, STE-aVR in addition to STD on admission ECG was strongly associated with left main/3-vessel disease and in-hospital adverse outcomes, but isolated STD was not. Our findings suggest the importance of evaluation of ST-segment deviation in 12 leads including aVR in early risk stratification.
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