Wave In Lead aVR Research Articles

Electro‐anatomically confirmed sites of origin of ventricular tachycardia and premature ventricular contractions and occurrence of R wave in lead aVR: A proof of concept study

AbstractBackgroundThe R wave in lead aVR, during the wide QRS complex tachycardia, is commonly observed in a ventricular tachycardia (VT) arising from certain locations in the ventricles.ObjectivesThis was a retrospective and a proof of concept study to correlate the sites of origin of VT and premature ventricular contractions (PVCs) with the occurrence of R wave in lead aVR.MethodsPatients with VT or high density of PVCs were included. Surface and intracardiac electrograms were recorded during the arrhythmia. VTs and PVCs arising from the inferior, inferolateral, or apical region of the ventricles were grouped into Zone 2. Those arising from the other areas of the ventricles were grouped into Zone 1.ResultsSixty‐four patients were included in the study. The mean age was 57 years. There were 47 males. Among 64 patients with VT or PVCs, 28 patients had an R wave in aVR (43.7%), In 26 of 28 patients with an R wave in aVR, the site of origin of the arrhythmia was in Zone 2. The R wave in aVR was absent in 36 patients, 34 of whom had the origin of arrhythmia focus in Zone 1. The presence of an R wave in aVR correctly identified Zone 2 as a site of origin of the arrhythmia with high sensitivity (93%) and specificity (94%).ConclusionsThe presence of an R wave in aVR during wide QRS complex tachycardia or PVC is a valuable observation for identifying the site of origin of the arrhythmia and hence in distinguishing supraventricular tachycardia with aberrancy from VT.

Importance of Positive T-wave in Lead aVR and Major Adverse Cardiac Events in Patients with ST Elevation Myocardial Infarction: A Cohort Study

Introduction: It is well known that ST-Segment Elevation Myocardial Infarction (STEMI) is a significant contributor to both illness and death on a global scale. An Electrocardiogram (ECG) is an easily accessible bedside tool for diagnosing acute myocardial infarction. The T wave is usually negative in lead aVR (augmented unipolar right arm lead). However, a positive T wave in lead aVR has been shown to be associated with adverse in-hospital outcomes in patients with Acute Coronary Syndrome (ACS). Aim: To examine whether a positive T wave in lead aVR can be used as an indicator to predict Major Adverse Cardiac Events (MACE) during the hospital stay in patients with STEMI. Materials and Methods: A cohort study was performed at Shri BM Patil Medical College, Hospital and Research Centre, Vijayapura, involving patients admitted with STEMI. A total of 98 newly diagnosed ST-segment elevation patients were classified into two groups: Group A (positive T wave) in lead aVR with an amplitude of ≥ 0 mV, and Group B (negative T wave) in lead aVR with an amplitude of ≤0 mV. The hospital stays of STEMI patients were evaluated for adverse cardiac events. Chi-square test was used to assess relationships between categorical variables. Results: A total of 98 patients were evaluated, among which two were excluded. Hence, among 96 patients considered, 25 were females and 71 were male, with average ages of 57 years in Group A and 55 years in Group B. Among the 96 patients, 34 had positive T waves (35.4%) and 62 had negative T waves (64.5%) in lead aVR. The study revealed significantly higher rates of in-hospital MACE (heart failure, pulmonary oedema, and arrhythmias) in patients with positive T waves (Group A) in lead aVR, with p-values <0.05, which were statistically significant. Conclusion: The present study showed that a positive T wave in lead aVR is a valuable and cost-effective tool for predicting inhospital MACE in patients with STEMI. Utilising this simple and readily available ECG measurement could support clinicians in detecting high-risk patients who require closer monitoring and more aggressive interventions, potentially leading to improved patient outcomes and resource allocation.

A rapid wide complex tachycardia

A rapid wide complex tachycardia

Abstract 15858: Increased T Wave Amplitude in Lead Avr is a Strong Predictor of Reduced Left Ventricular Ejection Fraction in Suspected Acute Coronary Syndrome

Introduction: Non-invasive screening tools of cardiac function can play a significant role in the initial triage of patients with suspected acute coronary syndrome. Numerous ECG features have been previously linked with cardiac contractility in the general population. We sought to examine the prognostic value of positive T wave in lead aVR as a simple marker for real-time screening of reduced left ventricular ejection fraction (LVEF) in suspected acute coronary syndrome. Methods: We performed a secondary analysis of a prospective, observational cohort study of patients evaluated for suspected acute coronary syndrome. The parent study recruited consecutive patients evaluated at the emergency department of three UPMC-affiliated tertiary care hospitals. We included consecutive patients in whom an echocardiogram was performed during indexed encounter. LVEF were retrieved from the cardiologist-signed report. Baseline 12-lead ECGs were preprocessed using manufacturer specific algorithms. Amplitude of T wave in lead aVR were automatically measured at T peak in millivolts. Data analysis was performed using SPSS and alpha was set at 0.05 for two-sided hypothesis testing. Results: Our sample included 313 patients (aged 63 ± 15, 45% females, 35% Black). The mean LVEF was 57±13%. Most patients were in normal sinus rhythm (87%) or atrial fibrillation (13%). In Bivariate analysis, there was a significant and negative correlation between T wave amplitude in lead aVR and LVEF (Pearson r = -0.173, p = 0.002). T wave amplitude in lead aVR was significantly larger in patients with LVEF < 35% compared to their counterparts (-65±185 vs. -165±180, t(311) = -3.18, p = 0.002). Conclusions: Increasing T wave amplitude in lead aVR indicates lower LVEF in suspected acute coronary syndrome. This feature constitutes a simple visual marker to aid clinicians in identifying those with impaired cardiac function during emergency care.

The relationship between electrocardiographic findings and left ventricular apical thrombus.

Persistent ST segment elevation, fragmented QRS (fQRS), and prominent R wave in lead aVR (Goldberger sign) are the parameters associated with ventricular aneurysm. The goal of this report was to examine the association with electrocardiographic findings (persistent ST elevation, QRS duration, LBBB, and Fragmented QRS [fQRS]) and LV apical thrombus in subjects following anterior MI. The study was a prospective and cross-sectional analysis that comprised of 220 consecutive subjects diagnosed after anterior MI. The echocardiographic features of patients were evaluated at least 6 weeks after anterior MI. A 12-point ECG was collected on all subjects admitted to the hospital. LBBB, persistent ST elevation, QRS duration and fQRS were evaluated in these patients. The LV ejection fraction (LVEF) was lower in the thrombus group compared to the non-thrombus group (27.2 ± 7.1/33.2 ± 10.0, p=0.008). In patients with LV apical thrombus (LVAT); LBBB, persistent ST elevation, QRS duration and fQRS were higher compared to those without LVAT (p<0.05). We demonstrated that the electrocardiographic findings (persistent ST elevation, QRS duration, LBBB, and fQRS) were closely associated with LVAT, and these findings were used as indicators of LV thrombi in anterior MI patients.

Standard ECG in Brugada Syndrome as a Marker of Prognosis: From Risk Stratification to Pathophysiological Insights.

BackgroundThe 12‐lead ECG plays a key role in the diagnosis of Brugada syndrome (BrS). Since the spontaneous type 1 ECG pattern was first described, several other ECG signs have been linked to arrhythmic risk, but results are conflicting.Methods and ResultsWe performed a systematic review to clarify the associations of these specific ECG signs with the risk of syncope, sudden death, or equivalents in patients with BrS. The literature search identified 29 eligible articles comprising overall 5731 patients. The ECG findings associated with an incremental risk of syncope, sudden death, or equivalents (hazard ratio ranging from 1.1–39) were the following: localization of type 1 Brugada pattern (in V2 and peripheral leads), first‐degree atrioventricular block, atrial fibrillation, fragmented QRS, QRS duration >120 ms, R wave in lead aVR, S wave in L1 (≥40 ms, amplitude ≥0.1 mV, area ≥1 mm2), early repolarization pattern in inferolateral leads, ST‐segment depression, T‐wave alternans, dispersion of repolarization, and Tzou criteria.ConclusionsAt least 12 features of standard ECG are associated with a higher risk of sudden death in BrS. A multiparametric risk assessment approach based on ECG parameters associated with clinical and genetic findings could help improve current risk stratification scores of patients with BrS and warrants further investigation.RegistrationURL: https://www.crd.york.ac.uk/prospero/. Unique identifier: CRD42019123794.

Abstract 17216: Upright T Wave in Lead AVR and Risk of Mortality: A Systematic Review and Meta-Analysis

Background: Multiple observational studies have shown that positive T wave in lead AVR (PTAVR) on 12-lead electrocardiogram is associated with an increased risk of adverse outcomes including death. We sought to review the literature and conduct a meta-analysis to estimate the risk of mortality in patients with PTAVR. Methods: We searched multiple databases to investigate the association between PTAVR and risk of death. Studies that reported adjusted odds ratio (OR) or hazards ratio (HR) of the association between PTAVR and risk of death (all cause or cardiovascular mortality) were included. We used inverse variance approach to pool adjusted OR /HR and it’s 95 % confidence interval using a random effects model meta-analysis. Results: Out of 140 relevant studies, 17 studies were eligible. Twelve studies reported all-cause mortality and enrolled 4,122 patients, 1976 (47.9%) were males. PTAVR was associated with a significant increase in all-cause mortality, with a pooled adjusted OR 2.44, 95% CI [1.76-3.39], heterogeneity I 2 = 86%. Five studies reported cardiovascular mortality and enrolled 31,713 patients, 27,628 (87.1%) were males. PTAVR was associated with a significant increase in cardiovascular mortality, with a pooled adjusted OR 2.34, 95% CI [1.82-3.0], heterogeneity I 2 = 68%. Conclusion: Our findings suggest that PTAVR is significantly associated with a higher risk of death from any cause as well cardiovascular mortality. Lead AVR, an often neglected lead, should be carefully interpreted as it may provide important prognostic information. Further studies are warranted to examined the prognostic value of PTAVR in risk stratification when added to existing cardiovascular risk scores.

Usefulness of positive T wave in lead aVR in predicting arrhythmic events and mortality in patients with hypertrophic cardiomyopathy

Positive T wave in lead aVR (TaVR) has been associated with increased risk of adverse events in patients with various cardiovascular diseases. The purpose of this study was to investigate the prevalence and prognostic significance of positive TaVR in patients with hypertrophic cardiomyopathy (HCM). This study investigated 421 consecutive patients with HCM (177 women; age 51.1 ± 14.9 years). Admission electrocardiogram was examined for the presence of a positive TaVR. The primary endpoint was defined as a composite of major arrhythmic events (MAEs), which included sudden cardiac death, sustained ventricular tachycardia or fibrillation, or appropriate implantable cardioverter-defibrillator therapy. Cardiovascular mortality and all-cause death were evaluated as secondary endpoints. During median follow-up period of 6.0 years (interquartile range 4.0-11.6 years), 53 patients (12.6%) experienced the primary endpoint. On multivariable competing analysis, after adjusting for other confounding factors, the presence of positive TaVR was found to be an independent and strong predictor of the primary composite endpoint. Time-dependent receiver operating characteristic analysis, net reclassification index, and integrated discrimination improvement showed that the addition of positive TaVR to conventional HCM risk factors improved prediction of arrhythmic events. However, in subgroup analysis, a positive TaVR lost statistical significance in patients with apical HCM but remained significant in patients with all other hypertrophy patterns. Positive TaVR is associated with MAE in HCM patients, independent of and incremental to traditional risk factors.

The prognostic significance of a positive or isoelectric T wave in lead aVR in patients with acute coronary syndrome and ischemic ECG changes in the presenting ECG - Long-term follow-up data of the TACOS study

BackgroundA positive T wave in lead aVR (aVRT+) is an independent prognostic predictor of cardiovascular mortality in the general population as well as in cardiovascular disease. Subjects and methodsWe evaluated the prognostic impact of aVRT+ in an ECG recorded as close to hospital discharge as possible in acute coronary syndrome patients (n = 527). We divided the patients into three categories based on the findings in the admission ECG: ST elevation, global ischemia and other ST/T changes. ResultsIn the whole study population, and in all the three ECG subgroups, the 10-year all-cause mortality rate was higher in the aVRT+ group than in the aVRT− group. In Cox regression analysis, the age and gender adjusted hazard ratio (HR) for aVRT+ to predict all-cause mortality in the whole study population was 1.43 (95% confidence interval [CI] 1.12–1.83; p = 0.004). To predict cardiovascular mortality, the age and gender adjusted HR for aVRT+ was 1.54 (95% CI 1.14–2.07; p = 0.005) in the whole study population and 2.07 (95% CI 1.07–4.03; p = 0.032) in the category with other ST/T changes. ConclusionIn ACS patients with or without ST elevation, but with ischemic ST/T changes in their presenting ECG, a positive or isoelectric T wave in lead aVR in an ECG recorded in the subacute in-hospital stage is associated with all-cause and cardiovascular mortality during long-term follow-up. Clinicians should pay attention to this simple ECG finding at hospital discharge.

Association of the positive T wave in lead aVR with short-term mortality in patients with acute pulmonary embolism

Background: Lead aVR provides prognostic information in various settings for patients with cardiovascular diseases. The present study aimed to investigate the prognostic value of a positive T wave in lead aVR (TaVR) for patients with acute pulmonary embolism (APE).Methods: We screened a total of 412 consecutive patients who were hospitalised with a diagnosis of APE between 2008 and 2018. We investigated electrocardiograms (ECGs) for the presence of a positive TaVR and classified other abnormal ECG findings. Additionally, clinical data, such as echocardiographic findings were recorded, and pulmonary embolism severity index (PESI) scores were calculated. The predictors of mortality at 30 days were investigated as the clinical outcome by logistic regression analysis.Results: In our study population, 54 patients (13.1%) died within 30 days. The prevalence of female gender, congestive heart failure, chronic obstructive pulmonary disease, and mean PESI scores were significantly higher in patients with a positive TaVR compared to those without it. Systolic blood pressure of patients with positive TaVR was significantly lower than that of patients without positive TaVR. In multivariate regression analysis; PESI scores (OR: 1.03; 95% CI: 1.01–1.04, p < .01), Right ventricular end-diastolic diameter (RVEDD) (OR: 1.07 95% CI: 1.01–1.13, p = .02), and a positive TaVR (OR: 4.41; 95% CI: 1.63–11.96, p < .01) were independently correlated with mortality.Conclusion: Positive TaVR, PESI scores, and RVEDD at hospital admission may have prognostic value in patients with APE. Positive T wave in lead aVR could be a useful marker in early risk stratification of pulmonary embolism.

Simple electrocardiographic criteria for rapid identification of wide QRS complex tachycardia: The new limb lead algorithm

The electrocardiogram (ECG) is essential for the differential diagnosis of wide QRS complex tachycardia (WCT). The purpose of this study was to evaluate the diagnostic value of a novel ECG algorithm on the basis of the morphological characteristics of the QRS on the limb leads. The limb lead algorithm (LLA) was evaluated by analyzing 528 monomorphic WCTs with electrophysiology-confirmed diagnoses. In the LLA, ventricular tachycardia (VT) is diagnosed in the presence of at least 1 of the following: (1) monophasic R wave in lead aVR; (2) predominantly negative QRS in leads I, II, and III; and (3) opposing QRS complex in the limb leads: concordant monophasic QRS in all 3 inferior leads and concordant monophasic QRS in 2 or 3 of the remaining limb leads with a polarity opposite to that of the inferior leads. The diagnostic performance of the LLA was compared with that of the Brugada, Vereckei, and R-wave peak time (RWPT) algorithms. Of 528 WCT cases, 397 were VT and 131 supraventricular tachycardia. The interobserver agreement for the LLA was excellent (κ = 0.98), better than that for the other algorithms. The overall accuracy of the LLA (88.1%) was similar to that of Brugada (85.4%) and Vereckei (88.1%) algorithms but was higher than that of the RWPT algorithm (70.8%). The LLA had a lower sensitivity (87.2%) than did Brugada (94.0%) and Vereckei (92.4%) algorithms, but not the RWPT algorithm (67.8%). Furthermore, the LLA showed a higher specificity (90.8%) than did Brugada (59.5%), Vereckei (76.3%), and RWPT (80.2%) algorithms. The LLA is a simple yet accurate method to diagnose VT when approaching WCTs on the ECG.

Risk score for the exclusion of arrhythmic events in arrhythmogenic right ventricular cardiomyopathy at first presentation

AimsArrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetically determined heart muscle disorder associated with an increased risk of life-threatening arrhythmias in some patients. Risk stratification remains challenging. Therefore, we sought a non-invasive, easily applicable risk score to predict sustained ventricular arrhythmias in these patients. MethodsCohort of Patients who fulfilled the 2010 ARVC task force criteria were consecutively recruited. Detailed clinical data were collected at baseline and during follow up. The clinical endpoint was a composite of recurrent sustained ventricular arrhythmias and hospitalization due to ventricular arrhythmias. Multivariable logistic regression was used to develop models to predict the arrhythmic risk. A cohort including patients from other registries in UK, Canada and Switzerland was used as a validation population. ResultsOne hundred and thirty-five patients were included of whom 35 patients (31.9%) reached the endpoint. A model consisting of filtered QRS duration on signal-averaged ECG, non-sustained VT (NSVT) on 24 h-ECG, and absence of negative T waves in lead aVR on 12‑lead surface ECG was able to predict arrhythmic events with a sensitivity of 81.8%, specificity of 84.0% and a negative predictive value of 95.5% at the first presentation of the disease. This risk score was validated in international ARVC registry patients. ConclusionA risk score consisting of a filtered QRS duration ≥117 ms, presence of NSVT on 24 h-ECG and absence of negative T waves in lead aVR was able to predict arrhythmic events at first presentation of the disease.

The prognostic value of positive T wave in lead aVR: A novel marker of adverse cardiac outcomes in peripartum cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is an uncommon complication of pregnancy. Clinical courses of PPCM are markedly heterogeneous. Positive T waves in lead aVR (TaVR) are shown to be associated with adverse cardiac events in several cardiovascular diseases. We aimed to investigate the prevalence and prognostic role of positive TaVR in patients with PPCM. A total of 82 patients (mean age 29.1±6.3years) with the diagnosis of PPCM were enrolled. Presentation electrocardiogram (ECG) was investigated for presence of a positive TaVR. The median follow-up duration was 67.0months. The primary endpoint was defined as composite cardiac events, including cardiac death, arrhythmic events, or persistent left ventricular systolic dysfunction. Patients with positive T wave in lead aVR showed higher rates for persistent left ventricular systolic dysfunction, arrhythmic events, and cardiac death compared to patients without it. In multivariate logistic regression analysis, after adjusting for other confounding factors, the presence of positive TaVR was found to be as an independent and strong predictor of primary composite endpoint (odds ratio 6.21, 95% CI 1.45-26.51; p=0.014). In Kaplan-Meier survival analysis, both primary and secondary endpoints occurred more frequently in the positive TaVR group. Using the cut-off level of 0.25mV, T-wave amplitude in lead aVR predicted primary endpoint with a sensitivity of 100% and specificity of 100%. Positive T wave in lead aVR, as a simple and feasible electrocardiographic marker, seems to be a novel predictor of adverse cardiovascular outcomes in patients with PPCM.

Risk management in early stage arrhythmogenic cardiomyopathy associated with Provocable Brugada ECG

Risk factors of malignant tachyarrythmias should be assessed in cases with early stage arrhythmogenic cardiomyopathy and provocable Brugada ECG. Spontaneous right precordial coved-type ST segment elevation, tall R wave in lead aVR, QRS fragmentation, 1° AV block, inducibility during electrophysiological examination, low amplitude coved-type ST elevation and localised right precordial QRS prolongation should be tested in 20 out of 128 patients. Only QRS fragmentation and localised right precordial QRS prolongation were positive in these patients. QRS fragmentation was positive in two patients, one with aborted sudden cardiac and one patient without any further arrhythmic events. Localised right precordial QRS prolongation was positive in five patients with serious arrhythmic events – four cases with previous ventricular fibrillation and one case with subsequent slow ventricular tachycardia. All other risk factors could be ruled out. In summary, localised right precordial QRS prolongation seems to be the strongest risk marker in cases of developing arrhythmogenic cardiomyopathy and provocable Brugada ECG.

Prognostic value of positive T wave in lead aVR in patients with non-ST segment myocardial infarction.

Lead aVR provides prognostic information in various settings in patients with ischemia. We aim to investigate the role of a positive T wave in lead aVR in non-ST segment myocardial infarction (NSTEMI). In a prospective cohort study, we included 400 patients with NSTEMI. Presentation electrocardiogram (ECG) was investigated for presence of a positive T wave as well as ST segment elevation (STE) in aVR and study variables were compared. Predictors of primary outcome defined as hospital major adverse cardiovascular events (MACE) and secondary outcome, defined as three-vessel coronary disease and/or left main coronary artery stenosis (3VD/LMCA) stenosis in angiography, were determined in multivariate logistic regression analysis. Patients with a positive T wave in aVR were significantly older and were more likely to be female. Left ventricular ejection fraction was significantly lower in patients of positive T group. Positive T group was more likely to have 3VD/LMCA stenosis (58.3% vs. 19.8%, p<.001). The prevalence of a positive T wave in aVR was significantly higher in MACE group (54.9 % vs. 24.8%, p<.001). However, in multivariate analysis, it was not an independent predictor of MACE (OR: 1.083 95% CI: [0.496-2.365], p: .841). Though, it was independently associated with presence of 3VD/LMCA stenosis (OR: 3.747 95% CI: [2.058-6.822], p<.001). Though positive T wave in lead aVR was more common in patients with MACE; it was not an independent predictor. Additionally, a positive T wave in aVR was an independent predictor of 3VD/LMCA stenosis in NSTEMI.

Usefulness of upright T wave in lead aVR for predicting short-term prognosis of patients with ischemic stroke

BackgroundUpright T wave in lead aVR (TaVR) has recently been reported to be associated with cardiovascular death and mortality in general population and in patients with prior cardiovascular disease (CVD). However, the evidence for the predictive ability of TaVR in patients with ischemic stroke (IS) is lacking. MethodsA total of 625 consecutive patients with IS (mean age: 66 ± 12 years; 379 male) were enrolled in this study between January 2013 and December 2014. Patients were divided into upright TaVR (≥0 mV; n = 201) and negative TaVR (<0 mV; n = 424) groups. All patients were evaluated with respect to clinical features and in-hospital clinical results. ResultsOverall, the prevalence of upright TaVR was 32.2% at baseline. Patients with an upright TaVR were older, had a higher percentage of CVD and hypertension, higher level of MB isoenzyme of creatine kinase (CKMB), faster heart rate, higher rate of QT prolongation > 450 ms, higher rate of negative T in lead II, higher rate of negative T in lead V6, higher rate of ST depression, and longer QTc duration. During the mean follow-up period of 20.0 ± 5.8 months, 29 (4.6%) patients experienced all-cause death and 12 (1.9%) patients experienced cardiovascular death, the primary end point. Concomitantly, 94 (15%) patients experienced recurrence of IS, the secondary end point. After adjusting for clinical covariates, upright TaVR was independently associated with all-cause death [hazard ratio (HR): 2.88, 95% confidence intervals (CI): 1.07–7.73], cardiovascular death (HR: 3.04, 95% CI: 1.07–8.64), and IS recurrence (HR: 1.86, 95% CI: 1.08–3.20). ConclusionsUpright TaVR in patients with IS is associated with increased mortality and recurrence of IS.

P887Positive T wave in lead aVR: electrocardiographic sign in myocarditis

P887Positive T wave in lead aVR: electrocardiographic sign in myocarditis

Usefulness of the R-Wave Sign as a Predictor for Ventricular Tachyarrhythmia in Patients With Brugada Syndrome

Brugada syndrome (BrS) is an autosomal dominant channelopathy which is responsible for a large number of sudden cardiac deaths in young subjects without structural abnormalities. The most challenging step in management of patients with BrS is identifying who is at risk for developing malignant ventricular tachyarrhythmia (VTA). In patients with BrS, conduction delay in the right ventricular outflow tract (RVOT) causes a prominent R wave in lead aVR. This electrocardiographic parameter can be useful to detect these high-risk patients. The goal of this study was to test the significance of R-wave elevation in lead aVR as a predictor for VTA in patients with BrS. In this retrospective study, we included 132 patients with BrS (47 ± 15years, 65% men) who visited the outpatient clinic for cardiogenetic screening. Patients' medical records were examined for the presence of a positive R-wave sign in lead aVR and VTA. A positive R-wave sign in lead aVR was observed in 41 patients (31%). This sign was more frequently observed in patients who experienced VTA (n= 24) before the initial diagnosis, during electrophysiological studies, or during follow-up (p <0.001). The positive R-wave sign occurred more frequently in symptomatic patients with a history of an out of hospital cardiac arrest, VTA, or syncope than asymptomatic patients (60% vs 26%; p= 0.002). During the follow-up period, this sign was more frequently detected in patients who developed either de novo (50%) or recurrent VTA (80%) (p= 0.017). Multivariable regression analysis showed that R-wave sign is an independent predictor for VTA development (odds ratio 4.8, 95% confidence interval 1.79 to 13.27). The presence of a positive R-wave sign in lead aVR is associated with the development of VTA. In conclusion, positive R-wave sign in lead aVR can be used to identify patients with BrS at risk for malignant VTA.

Positive T wave in lead aVR as an independent predictor for 1-year major adverse cardiac events in patients with first anterior wall ST-segment elevation myocardial infarction.

Positive T wave in lead aVR has been shown to predict an adverse in-hospital outcome in patients with anterior wall ST-segment elevation myocardial infarction (STEMI). However, the prognostic value of positive T wave in lead aVR on a long-term outcome has not been fully explored. We performed a retrospective analysis of 190 consecutive patients with first anterior wall STEMI who underwent an emergent coronary angiogram. Patients were divided into those with positive T wave>0mV and those with negative T wave≦0mV in lead aVR. Baseline and angiographic characteristics, and in-hospital revascularization procedures were recorded. In addition, in-hospital and 1-year major adverse cardiac events (MACE) including death, recurrent myocardial infarction, and target vessel revascularization were recorded. Among 190 patients, 37 patients (19%) had positive T wave and 153 patients (81%) had negative T wave in lead aVR. Patients with positive T wave had higher rate of left main disease defined as stenosis ≥50% (11% vs. 2%, p=.028) than those with negative T wave. Patients with positive T wave had higher rate of 1-year MACE (38% vs. 13%, p<.001) driven by higher all-cause mortality (27% vs. 5%, p<.001). Positive T wave was an independent predictor for 1-year MACE (OR 2.74; 95% CI 1.04-7.15; p=.04). Positive T wave in lead aVR was an independent predictor for 1-year MACE in patients with first anterior wall STEMI.

Validation of the Prognostic Utility of the Electrocardiogram for Acute Drug Overdose.

BackgroundWhile it is certain that some emergency department patients with acute drug overdose suffer adverse cardiovascular events (ACVE), predicting ACVE is difficult. The prognostic utility of the ECG for heterogeneous drug overdose patients remains to be proven. This study was undertaken to validate previously derived features of the initial ECG associated with ACVE in this population.Methods and ResultsWe performed a prospective validation cohort study to evaluate adult emergency department patients with acute drug overdose at 2 urban university hospitals over 5 years in whom an emergency department admission ECG was performed. Exclusion criteria were alternate diagnoses, anaphylaxis, chronic drug toxicity, and missing outcome data. ACVE was defined as any of the following: circulatory shock, myocardial injury, ventricular dysrhythmia, or cardiac arrest. Blinded cardiologists interpreted ECGs for previously derived predictors of ACVE (ectopy, QT prolongation, nonsinus rhythm, ischemia/infarction), QT dispersion, and prominent R wave in lead AVR. Of 589 patients who met inclusion criteria (48% male, mean age 42), there were 95 ACVEs (39 shock, 64 myocardial injury, 26 dysrhythmia, 16 cardiac arrest). The most common drug exposures were as follows: benzodiazepines, opioids, and acetaminophen. Previously derived criteria were highly predictive of ACVE, with QT correction >500 ms as the highest risk feature (OR 11.2, CI 4.6–27).ConclusionsThis study confirms that early ECG evaluation is essential to assess the cardiovascular prognosis and medical clearance of emergency department patients with acute drug overdose. Furthermore, this study validates previously derived high‐risk features of the admission ECG to risk stratify for ACVE in this patient population.