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

Abstract

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.

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

“…In a National Health and Nutrition Examination Survey-III substudy, aVRT+ was the strongest multivariate predictor of cardiovascular mortality (24). In the Oregon Sudden Unexpected Death Study, a positive T wave in aVR was associated with sudden cardiac death in the multivariate analysis in some studied subpopulations, including those with normal LV ejection fraction, normal corrected QT interval and no diabetes (25).…”

Evaluating of Red Blood Cell Distribution Width, Comorbidities and Electrocardiographic Ratios as Predictors of Prognosis in Patients with Pulmonary Hypertension

“…Over time, various functional parameters have been reported as reliable mortality predictors for primary cardiovascular diseases [ 4 , 5 , 6 ]. For example, due to their sensitivity, remarkable findings have been obtained when analysing electrocardiographic test results [ 7 , 8 ], while isolated data from other individual diagnostic tests have been shown to predict mortality [ 9 , 10 ].…”

Association of Lead aVR T‐wave Amplitude With Cardiovascular Events or Mortality Among Prevalent Dialysis Patients

“…However, the significance of a lead aVR has sometimes been ignored. In non‐CKD patients, positive T‐wave of aVR (aVRT) or amplitude of the aVRT wave was significantly associated with sudden death or CV mortality . Recently, in dialysis patients, positive aVRT was also associated with all‐cause mortality , CV related mortality or sudden death .…”