The Prognostic Value Of ST-T Changes In Lead AVR For Patients With Non-ST-segment Elevation Myocardial Infarction

Objective:The purpose of this study was to investigate the prognostic value of ST-T changes in lead aVR for patients with non-ST-segment elevation myocardial infarction(NSTEMI)underwent percutaneous coronary intervention(PCI).Methods:256 NSTEMI patients underwent PCI were retrospectively included,according to the feature of T wave and ST segment in aVR lead came from first electrocardiogram after admission,256 patients were independently divided into upright T wave group(n=57),non-upright T wave group(n=199),ST-segment elevation group(n=60),non-ST-segment elevation group(n=196).Observing the changes of upright T wave group and ST segment elevation group during hospitalization,according to the independent changes of T wave and ST segment in lead aVR,patients in the upright T wave group were divided into T wave non-recovery group(n=35)and T wave recovery group(n=22)according to the changes of T-wave in aVR lead within 24-48 hours after admission,and patients in the ST-segment elevation group were divided into ST-segment non-regression group(n=22)and ST-segment regression group(n=38)according to the ST-segment regression within 24 hours after admission.Clinical data of the patients after admission,adverse events during hospitalization and major adverse cardiac and cerebrovascular events(MACCE)during follow-up after discharge were collected.Univariate analysis was used to compare the clinical characteristics and prognosis of the patients in each group.The independent predictors for MACCE in NSTEMI patients during follow-up were investigated by unconditional logistic regression analysis.All measurement data in the independent predictors were analyzed by receiver operating characteristic curve(ROC curve)and area under the cure(AUC)to obtain the best cut-off point and prediction accuracy.Results:1.Compared with the non-upright T wave group,patients in upright T wave group included less male(70.2%vs 82.9%,P<0.05),combined with type 2 diabetes mellitus were more common(45.6%vs 30.2%,P<0.05);they had higher proportion of Killip class≥II(50.9%vs 30.2%,P<0.05),higher GRACE score[(158.5±46.3)points vs(137.4±36.9)points,P<0.05],higher the peak value of NT-pro BNP[1830.0(474.5,3845.0)ng/L vs 400.0(150.5,2084.0)ng/L,P<0.05),lower left ventricular ejection fraction(LVEF)[59.0(52.0,61.5)%vs 60.0(55.5,63.0)%,P<0.05];they had lower proportion of 1-vessel disease(5.3%vs 18.1%,P<0.05),higher proportion of 2-vessel disease(50.9%vs 34.2%,P<0.05);they had higher proportion of severe Gensini score(54.4%vs 39.7%,P<0.05),higher proportion of the infarct-related artery(IRA)of left anterior descending(LAD)(45.6%vs 30.7%,P<0.05);they had higher incidence of adverse events during hospitalization(49.1%vs 23.1%,P<0.05)and MACCE during follow-up(52.8%vs 25.8%,P<0.05).2.Compared with the non-ST segment elevation group,patients in ST segment elevation group was older[(67.0±11.9)years vs(61.4±12.4)years,P<0.05];they combined with hypertention(75.0%vs 58.2%,P<0.05),type 2 diabetes mellitus(50.0%vs 28.6%,P<0.05)were more common;they had higher proportion of Killip class≥II(55.0%vs 28.6%,P<0.05),higher GRACE score[(168.8±42.2)points vs(133.4±35.2)points,P<0.05],higher peak value of NT-pro BNP[2593.5(430.5,5573.5)ng/L vs 365.0(151.0,1830.0)ng/L,P<0.05),lower LVEF[57.5(51.5,61.0)%vs 60.0(56.0,63.0)%,P<0.05],longer hospital stays[9.0(6.0,11.5)days vs 6.0(5.0,8.0)days,P<0.05];they had more three-vessel disease(3-VD)(65.0%vs 41.3%,P<0.05)and left main coronary artery(LM)lesions(30.0%vs 3.6%,P<0.05),more proportion of severe Gensini score(68.3%vs 35.2%,P<0.05),more IRA of LM(5.0%vs 0.5%,P<0.05);they had higher incidence of adverse events during hospitalization(60.0%vs 19.4%,P<0.05)and MACCE during follow-up(45.5%vs 27.6%,P<0.05).3.Unconditional logistic regression showed that GRACE score(OR:1.018,95%CI:1.007-1.029,P=0.001),ST segment elevation in aVR lead(OR:7.901,95%CI:3.586-17.407,P=0.000),ALB(OR:0.871,95%CI:0.788-0.964,P=0.007),LVEF(OR:0.936,95%CI:0.8955-0.978,P=0.003)were independent predictors for MACCE during follow-up in NSTEMI patients.ROC curve analysis showed that the best cut-off values of GRACE score,LVEF and ALB were 141.5 points(AUC 0.752),59.5%(AUC 0.684)and 40.0 g/L(AUC 0.679)and the AUC of the predicted probability of ST segment elevation in aVR lead is 0.619.4.Compared with the T wave recovery group,patients in T wave non-recovery group included less male(60.0%vs 86.4%,P<0.05),they had lower BMI[(22.4±2.7)kg/m~2vs(24.6±1.9)kg/m~2,P<0.05],higher proportion of Killip class≥II(65.7%vs 27.3%,P<0.05),lower ALB[(36.8±3.6)g/L vs(38.8±2.9)g/L,P<0.05],higher the peak value of NT-pro BNP[2998.0(432.0,6550.0)ng/L vs 1584.5(937.0,3930.0)ng/L,P<0.05],lower LVEF[(52.1±11.6)%vs(59.7±8.8)%,P<0.05];they had higher incidence of adverse events during hospitalization(62.9%vs 27.3%,P<0.05)and MACCE during follow-up(64.5%vs 36.4%,P<0.05).Unconditional logistic regression showed that GRACE score(OR:1.026,95%CI:1.008-1.044,P=0.004)and T wave non-recovery in aVR lead(OR:4.963,95%CI:1.259-19.969,P=0.022)were independent predictors for MACCE during follow-up in NSTEMI patients with upright T wave in aVR lead.ROC curve analysis showed that the best cut-off value of the GRACE score was 152.5 points(AUC 0.756),and the AUC of the predicted probability of T wave non-recovery in lead aVR was 0.659.5.Compared with the ST-segment resolution group,patients in ST-segment non-resolution group had higher Cys-c[1.5(1.1,1.9)mg/L vs 1.2(1.1,1.4)mg/L,P<0.05],they had higher incidence of adverse events during hospitalization(81.8%vs 47.4%,P<0.05)and MACCE during follow-up(65.0%vs 34.3%,P<0.05).Unconditional logistic regression showed GRACE score(OR:1.032,95%CI:1.010-1.054,P=0.005)and ST-segment non-resolution in aVR lead OR:5.313,95%CI:1.363-20.713,P=0.016)were independent predictors for MACCE during follow-up in NSTEMI patients with ST segment elevation in aVR lead.The ROC curve analysis showed that the best cut-off value of the GRACE score was 145.0 points(AUC 0.711),and the AUC of the predicted probability of ST-segment non-resolution in lead aVR was 0.658.Conclusion:1.NSTEMI patients with upright T wave,ST-segment elevation in lead aVR came from first electrocardiogram after admission had more serious condition and worse prognosis.ST-segment elevation in lead aVR was an independent predictor for MACCE during follow-up in NSTEMI patients.2.T wave non-recovery in aVR lead was an independent predictor for MACCE during follow-up in NSTEMI patients with upright T wave in aVR lead.3.ST-segment non-resolution in aVR lead was an independent predictor for MACCE during follow-up in NSTEMI patients with ST segment elevation in aVR lead.