Author + information
- Masami Kosuge, MD∗ (, )
- Keiji Uchida, MD,
- Kiyotaka Imoto, MD,
- Susumu Isoda, MD,
- Norihisa Karube, MD,
- Toshiaki Ebina, MD,
- Kiyoshi Hibi, MD,
- Hidefumi Nakahashi, MD,
- Kengo Tsukahara, MD,
- Noriaki Iwahashi, MD,
- Nobuhiko Maejima, MD,
- Munetaka Masuda, MD,
- Satoshi Umemura, MD and
- Kazuo Kimura, MD
- ↵∗Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
In type A acute aortic dissection (AAD), ST-T changes on the admission electrocardiogram (ECG) are associated with poor outcomes (1,2). Although ST-segment elevation in lead aVR (STE-aVR) is an ECG marker of severe acute myocardial ischemia (3), its prognostic significance in type A AAD remains unknown. We studied the relationship of admission ECG findings to clinical features at admission and in-hospital death in 409 patients (mean age, 64 ± 12 years; 231 men; mean time from symptom onset to admission, 3.1 ± 2.4 h; the rate of urgent surgery, 90%) with type A AAD who were admitted within 12 h from symptom onset. The Ethics Committee at our institution approved the study, and all subjects gave informed consent.
Twelve-lead ECGs were recorded on admission. Left ventricular hypertrophy was defined using the Sokolow-Lyon voltage criteria. We used globally accepted criteria defining ST-T changes (4) to diagnose acute myocardial ischemia. Patients were divided into the 4 groups: no significant ST-T changes (n = 110, group A), bundle branch block or left ventricular hypertrophy (n = 86, group B), and the absence (n = 163, group C) or the presence (n = 50, group D) of STE-aVR ≥0.05 mV with ST-T changes in other leads. Renal dysfunction was defined as an estimated glomerular filtration rate calculated using serum creatinine levels on admission of <60 ml/min/1.73 m2.
Data were compared by 1-way analysis of variance or chi-square analysis. Multivariate logistic regression analysis was used to identify clinical predictors at admission of in-hospital mortality among the 4 ECG patterns and variables associated (p < 0.05) with this outcome on univariate analysis.
In groups A, B, C, and D, the rates of shock were 2.7%, 12.8%, 19.0%, and 64.0%; the rates of cardiac tamponade were 3.6%, 20.9%, 17.8%, and 60.0%; and the rates of renal dysfunction were 40.9%, 55.8%, 56.4%, and 68.0% (all p < 0.01), respectively. Among 370 patients who underwent urgent surgery in groups A, B, C, and D, the rates of coronary ostial involvement were 3.0%, 2.6%, 9.9%, and 31.8% (p < 0.01); the rates of left coronary artery involvement were 2.0%, 1.3%, 0.7%, and 18.2% (p < 0.01); the rates of right coronary artery involvement were 1.0%, 1.3%, 7.9%, and 9.1% (p = 0.02); and the rates of both left and right coronary artery involvement were 0%, 0%, 1.3%, and 4.5% (p = 0.07), respectively. Age, sex, time from symptom onset to admission, and the rate of urgent surgery were similar among the 4 groups.
STE-aVR was associated with the highest in-hospital mortality, regardless of treatment strategy (Figure 1). Age, shock, cardiac tamponade, and renal dysfunction were included as variables in the multivariate analysis, but were not significantly related to in-hospital death. STE-aVR was the strongest predictor of in-hospital death (odds ratio: 23.4; 95% confidence interval: 6.10 to 62.2; p < 0.01), followed by no surgical treatment (odds ratio: 10.4; 95% confidence interval: 3.71 to 29.2; p < 0.01).
This study demonstrated that in patients with type A AAD, STE-aVR at presentation was associated with serious conditions such as shock, cardiac tamponade, or coronary ostial involvement and was the strongest predictor of in-hospital death.
In acute coronary syndrome (ACS), STE-aVR reflects severe acute myocardial ischemia due to severe coronary artery disease (3). In ST-segment elevation myocardial infarction, STE-aVR is caused by transmural ischemia in the basal septum, often resulting from obstruction of the left main or the proximal left anterior descending coronary artery. In non–ST-segment elevation ACS, lead aVR is referred to as a cavity lead, and STE-aVR might reflect global subendocardial ischemia of the left ventricle, often associated with left main or 3-vessel disease.
In type A AAD, the mechanisms underlying STE-aVR remain unclear. Under certain limited conditions, however, severe acute myocardial ischemia is thought to provoke STE-aVR. If the left coronary artery ostium is completely obstructed, transmural ischemia in the basal septum can cause STE-aVR. In coronary ostial involvement (especially of the left coronary artery) associated with severe stenosis but not complete occlusion, global subendocardial ischemia of the left ventricle can also cause STE-aVR. Furthermore, serious conditions, such as shock and cardiac tamponade, can lead to severe subendocardial ischemia of the left ventricle (2), resulting in STE-aVR. In any of these conditions, patients with STE-aVR are considered to have a poor prognosis. To our knowledge, this is the first study to demonstrate the prognostic significance of STE-aVR in type A AAD.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation