Associations of positive T wave in lead aVR with hemodynamic, coronary, and left ventricular angiographic findings in anterior wall old myocardial infarction

Shinozaki, Kazuo; Tamura, Akira; Kadota, Jun‐ichi

doi:10.1016/j.jjcc.2010.12.002

Cited by 22 publications

(41 citation statements)

References 18 publications

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“…We found subjects with a positive/flat T wave in aVR to have a greater burden of classical cardiovascular risk factors (i.e. older age, diabetes, hypertension, low LVEF, and previous MI), which is consistent with published studies [17–22]. However, when looking at the subgroup with normal LVEF (≥ 50%), normal QTc (≤ 450ms), and without diabetes, a positive/flat T wave in aVR still remained significantly associated with SCD, suggesting that this ECG finding may have a specific association with ventricular arrhythmias.…”

Section: Discussionsupporting

confidence: 92%

“…It has also been postulated that ischemia in the anterior and inferior wall may cause spatial directional changes in the repolarization vector leading to less negative or positive T waves in lead aVR [15]. One study looking at coronary angiography data in patients with old anterior wall myocardial infarction (MI) found those with a positive T wave in lead aVR had greater likelihood of a longer left anterior descending artery (LAD), ≥ 75% stenosis of the LAD and multi-vessel disease compared to those with negative T wave (although the latter two were not statistically significant), supporting ischemia as one cause for repolarization abnormalities leading to T wave positivity in lead aVR [22]. …”

Section: Discussionmentioning

confidence: 99%

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T-wave reversal in the augmented unipolar right arm electrocardiographic lead is associated with increased risk of sudden death

Phan

Narayanan

Uy‐Evanado

et al. 2015

J Interv Card Electrophysiol

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Background Repolarization abnormalities are associated with ventricular arrhythmias and published studies report that a reversal of T wave polarity (positive or flat T wave) in lead aVR may be linked to increased cardiovascular mortality. We aimed to evaluate whether a positive or flat T wave in aVR is a risk marker for sudden cardiac death (SCD). Methods SCD Cases from the Oregon Sudden Unexpected Death Study (catchment population ~ 1 million) were compared to geographic controls with coronary artery disease and no history of SCD. Archived electrocardiograms performed prior and unrelated to the SCD event were evaluated. Results SCD cases (n=691, 67.6 ± 14.9 yrs, 69% male) were more likely than controls (n=663, 66.2 ± 11.6 yrs, 67% male) to have diabetes (40% vs 32%; p<0.01), left ventricular ejection fraction (LVEF) ≤ 35% (27% vs 11%; p<0.01), prolonged QTc (≥ 450ms; 54% vs 28%; p<0.01), positive (19% vs 13%; p<0.01) or flat T wave (14% vs 7%; p<0.01) in aVR. On multivariable analysis, a positive/flat T wave in aVR was independently associated with SCD (OR 1.9, 95% CI 1.3–2.8, p<0.01). However, a positive T wave alone in aVR lost statistical significance in patients with LVEF ≤ 35% and QTc ≥ 450ms. In a subgroup analysis among patients with normal LVEF, QTc, and no diabetes, a positive T wave in aVR (but not a flat T wave) remained associated with SCD (OR 2.8, 95% CI 1.2–6.1, p<0.01). Conclusions A positive or flat T wave in lead aVR was associated with SCD in subsets of patients. This simple ECG marker in the often-ignored lead may contribute to enhancement of SCD risk stratification, and warrants further evaluation.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

T-wave reversal in the augmented unipolar right arm electrocardiographic lead is associated with increased risk of sudden death

Phan

Narayanan

Uy‐Evanado

et al. 2015

J Interv Card Electrophysiol

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“…Although the underlying mechanisms explaining why an upright aVRT occurs on the ECG are not identified, it has been suggested that a long left anterior descending artery and multivessel disease, in both cases, along with an ischemically injured myocardium in these areas of the heart, would be expected to make a normally negative T-wave inverted and lead to a flat or positive T-wave [20,21,22,23]. Ayhan et al [22] suggested that a positive T-wave in lead aVR in patients with anterior ST segment elevation myocardial infarction undergoing primary PCI may be caused by multivessel disease, and Joki et al [4] evaluated coronary angiography in incident hemodialysis patients and showed that more than half of the patients had significant CAD; it should be noted that >70% of CAD patients had multivessel disease.…”

Section: Discussionmentioning

confidence: 99%

Usefulness of an Upright T-Wave in Lead aVR for Predicting the Short-Term Prognosis of Incident Hemodialysis Patients: A Potential Tool for Screening High-Risk Hemodialysis Patients

et al. 2015

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Background/Aims: An upright T-wave in lead aVR (aVRT) has recently been reported to be associated with cardiovascular death and mortality among the general population and patients with prior cardiovascular disease (CVD). However, evidence for the predictive ability of aVRT in patients with chronic kidney disease is lacking. Therefore, a hospital-based, prospective, cohort study was conducted to evaluate the predictive ability of an upright aVRT for the short-term prognosis in incident hemodialysis patients. Methods: Among 208 patients who started maintenance hemodialysis, 79 with preexisting CVD (CVD cohort) and 129 with no history of CVD (non-CVD cohort), were studied. An upright and non-upright aVRT were defined as a wave with a positive deflection in amplitude of ≥0 mV and a negative deflection in amplitude of <0 mV, respectively. The endpoint was all-cause death. Results: Overall, the prevalence of an upright aVRT was 22.6% at baseline. During the mean follow-up period of 2.1 ± 1.0 years, 33 deaths occurred. Cumulative survival rates at 3 years after starting dialysis in patients with an upright and non-upright aVRT were 50.0 and 80.7%, respectively, in the CVD cohort and 92.0 and 91.3%, respectively, in the non-CVD cohort. In the CVD cohort, multivariate Cox regression analysis showed that an upright aVRT was an independent predictor of death after adjusting for confounding variables. Conclusion: Among Japanese hemodialysis patients at high risk for CVD, an upright aVRT seems to be useful for predicting death.

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“…A few studies [23,24] have investigated the significance of T-wave positivity in lead aVR in prior MI. We [23] examined 122 patients with anterior wall prior MI and found that 20 patients with a T wave (≥ 0.1 mV) in lead aVR had higher pulmonary arterial, pulmonary capillary wedge, and LV end-diastolic pressures, a lower cardiac index, and a lower LV ejection fraction than 102 patients without such a T wave in lead aVR.…”

Section: T-wave Abnormality In Lead Avrmentioning

confidence: 99%

“…We [23] examined 122 patients with anterior wall prior MI and found that 20 patients with a T wave (≥ 0.1 mV) in lead aVR had higher pulmonary arterial, pulmonary capillary wedge, and LV end-diastolic pressures, a lower cardiac index, and a lower LV ejection fraction than 102 patients without such a T wave in lead aVR. The prevalence of a long LAD was significantly higher in the former group than in the latter group (60% vs 30.4%, P = 0.01), and none of the former group had an LAD that did not reach the apex.…”

Section: T-wave Abnormality In Lead Avrmentioning

confidence: 99%

Significance of lead aVR in acute coronary syndrome

Tamura¹

2014

WJC

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The 12-lead electrocardiogram (ECG) is a crucial tool in the diagnosis and risk stratification of acute coronary syndrome (ACS). Unlike other 11 leads, lead aVR has been long neglected until recent years. However, recent investigations have shown that an analysis of ST-segment shift in lead aVR provides useful information on the coronary angiographic anatomy and risk stratification in ACS. ST-segment elevation in lead aVR can be caused by (1) transmural ischemia in the basal part of the interventricular septum caused by impaired coronary blood flow of the first major branch originating from the left anterior descending coronary artery; (2) transmural ischemia in the right ventricular outflow tract caused by impaired coronary blood flow of the large conal branch originating from the right coronary artery; and (3) reciprocal changes opposite to ischemic or non-ischemic ST-segment depression in the lateral limb and precordial leads. On the other hand, ST-segment depression in lead aVR can be caused by transmural ischemia in the inferolateral and apical regions. It has been recently shown that an analysis of T wave in lead aVR also provides useful prognostic information in the general population and patients with prior myocardial infarction. Cardiologists should pay more attention to the tracing of lead aVR when interpreting the 12-lead ECG in clinical practice.

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Associations of positive T wave in lead aVR with hemodynamic, coronary, and left ventricular angiographic findings in anterior wall old myocardial infarction

Cited by 22 publications

References 18 publications

T-wave reversal in the augmented unipolar right arm electrocardiographic lead is associated with increased risk of sudden death

T-wave reversal in the augmented unipolar right arm electrocardiographic lead is associated with increased risk of sudden death

Usefulness of an Upright T-Wave in Lead aVR for Predicting the Short-Term Prognosis of Incident Hemodialysis Patients: A Potential Tool for Screening High-Risk Hemodialysis Patients

Significance of lead aVR in acute coronary syndrome

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