The prognostic effect of ST-elevation in lead aVR on coronary artery disease, and outcome in acute coronary syndrome patients: a systematic review and meta-analysis

Abstract

Background Rapid diagnosis of coronary artery disease has an important role in saving patients. The aim of this study is to evaluate if aVR lead ST-elevation (STE) can predict LM/3VD, left main (LM) disease, and three-vessel disease (3VD), outcome in acute coronary syndrome (ACS) patients. Methods In this systematic review and meta-analysis, 45 qualified studies were entered. Scopus, Pub med, Google scholar, Web of science, Cochrane library were searched on 12 November 2021. Results This systematic review includes 52,175 participants. In patients with STE, the total odds ratios for LM, 3VD, and LM/3VD were 5.48 (95% CI 3.88, 7.76), 2.21 (95% CI 1.78, 3.27), and 6.21 (95% CI 3.49, 11,6), respectively. STE in lead aVR was linked with in-hospital death (OR = 2.99, CI 1.90, 4.72) and 90-day mortality (OR = 3.09, CI 2.17, 4.39), despite the fact that it could not predict 30-day mortality (OR = 1.11, CI 0.95, 1.31). The STE > 1 mm subgroup had the highest sensitivity for LM (0.9, 95% CI 0.82, 0.98), whereas the STE > 0.5 mm (0.76, 95% CI 0.61, 0.90) subgroup had the highest sensitivity for LM/3VD. The appropriate cut-off point with highest specificity for LM/3VD and LM was STE > 1.5 mm (0.80, 95% CI 0.75, 0.85) and STE > 0.5 mm, respectively (0.75, 95% CI 0.67, 0.84, I2 = 97%). Conclusion The odds of LM and LM/3VD were higher than 3VD in ACS patients with STE in lead aVR. Also, STE > 0.5 mm was the best cut-off point to screen LM/3VD, whereas for LM diagnosis, STE > 1 mm had the highest sensitivity. Furthermore, LM/3VD had a higher overall specificity than LM.

Simultaneous ST-elevation in lead augmented vector right (aVR) and III in non-ST-elevation acute coronary syndromes

“…Over the past two decades the critical role of lead aVR has attracted increasing interest due to its possible association with left main or triple-vessel coronary artery disease or, as emphasized more recently, potential left main or proximal LAD occlusion. However, the sensitivity and specificity of lead aVR in the diagnosis remains controversial ( 11 - 13 ), urging us to conduct further investigation to gain a deeper knowledge of ST-elevation in aVR.…”

The “Neglected aVR Lead”: Kounis Syndrome of MINOCA Type, Severe Left Main or 3-Vessel Disease and Type A Dissecting Ascending Aortic Aneurysm

“…Studies have shown that identifying severe left main or 3-vessel disease with 80% sensitivity and 93% specificity can be achieved by observing ST-segment elevation of more than 1.0 mm in lead aVR along with widespread ST-segment depression in inferolateral leads, as seen in this patient. 1 , 2 , 4 Urgent coronary angiography was performed, confirming normal coronary arteries associated with Type I Kounis syndrome. Type I Kounis syndrome is similar to MINOCA and describes the syndrome in patients with normal or nearly normal coronary arteries and no risk factors for coronary artery disease.…”

“…The authors correctly diagnosed him with myocardial infarction with nonobstructive coronary arteries (MINOCA) of Kounis syndrome type I based on clinical and laboratory findings. 2 …”

Early predictors of severe left main and/or three‐vessel disease in patients with non‐ST‐segment elevation myocardial infarction: A dual‐center retrospective study

“…There are many studies that have been conducted to investigate the factors that can predict LM/3VD in patients with no-ST-segment elevation acute coronary syndrome (NSTE-ACS). Previous studies indicated that ST-segment elevation in lead aVR was an independent predictor for LM/3VD and the extent of LM/3VD in comparison to ST-segment deviation in other leads (D'Ascenzo et al, 2012;Kazemi et al, 2022). However, these studies did not evaluate LM/3VD severity by SS in patients with non-STsegment elevation myocardial infarction (NSTEMI).…”