aVR ST elevation: an important but neglected sign in ST elevation acute myocardial infarction

Aim This study evaluated the prognostic implications of aVR ST elevation during ST elevation acute myocardial infarction (AMI). Methods and resultsThe Hirulog and Early Reperfusion/Occlusion-2 study randomized 17 073 patients with acute ST elevation AMI within 6 h of symptom onset to receive either bivalirudin or heparin, in addition to streptokinase and aspirin. The treatments had no effect on the primary endpoint of 30-day mortality. Electrocardiographic recordings were performed at randomization and at 60 min after commencing streptokinase. aVR ST elevation ≥1 mm was associated with higher 30-day mortality in 15 315 patients with normal intraventricular conduction regardless of AMI location (14.7 vs. 11.2 for anterior AMI, P = 0.0045 and 16.0 vs. 6.4 for inferior AMI, P < 0.0001). After adjusting for summed ST elevation and ST depression in other leads, associations with higher mortality were found with aVR ST elevation of ≥1.5 mm for anterior [odds ratio 1.69 (95 CI 1.16 to 2.45)] and of ≥1 mm for inferior AMI [odds ratio 2.41 (95 CI 1.76 to 3.30)]. There was a significant interaction between aVR ST elevation and infarct location. Thirty-day mortality was similar with anterior and inferior AMI when aVR ST elevation was present (11.5 vs. 13.2, respectively, P = 0.51 with 1 mm and 23.5 vs. 22.5 respectively, P = 0.84 with ≥ 1.5 mm ST elevation). After fibrinolytic therapy, resolution of ST elevation in aVR to <1 mm was associated with lower mortality, while new ST elevation ≥1 mm was associated with higher mortality. Conclusion aVR ST elevation is an important adverse prognostic sign in AMI.