The role of ST-segment elevation in lead aVR in the risk assessment of patients with acute pulmonary embolism

Abstract

BACKGROUD AND AIM: Patients with acute pulmonary embolism (APE) present with highly variable symptoms and ECG abnormalities. As ST-elevation in lead aVR has recently been described to predict right ventricular dysfunction (RVD), we aimed to correlate this sign to the severity of APE. Three-hundred ninety-six consecutive patients (in centers a and b) with proven APE were retrospectively analysed with respect to 12-lead-ECG, symptoms, thrombus location, echocardiograpy, troponin T, initial therapy and outcome. Data were then compared between patients with and without aVR-ST-elevation. On admission aVR-ST-elevation was present in 34.3% (n=136). Presence of aVR-ST-elevation was assossiated with more severe clinical presentation (dyspnoea at rest 44.9 vs. 29.2%; p=0.002, hypotension 17.0 vs. 6.5%; p=0.001, syncope 16.2 vs. 6.5%; p=0.002), higher median troponin T levels (0.035 [0.01-0.2] versus 0.01 [0.01-0.02]; p<0.001), more frequent RVD (74.5 vs. 46.6%; p<0.001) and central located thrombi (50.8 vs. 29.2; p<0.001). Thrombolysis was used more frequently (29.1 vs. 7.5%; p<0.001) and in-hospital-mortality was increased (10.3 vs. 5.4%; p=0.07) when compared to patients without that sign. Mortality in intermediate-risk APE patients with aVR-ST-elevation was 8.9% compared to 0% in those without (p=0.04). In contrast, the presence of other classical ECG pattern of APE did not further increase mortality in intermediate-risk patients. ST-elevation in lead aVR is associated with a more severe course of APE, especially in patients with intermediate-risk. Therefore, aVR-ST-elevation might be useful in risk stratification of APE.