International Student Experiences: Neo-Racism and Discrimination

Abstract

Background: Lead aVR ST-segment deviation has been associated with increased mortality in ST-elevation myocardial infarction (STEMI) patients (pts) treated with fibrinolysis. However, its prognostic value in pts undergoing primary percutaneous coronary intervention (PCI) is unknown. We examined this question in nearly 5700 high-risk STEMI pts presenting <6 hours of symptom onset in the Assessment of PEXelizumab in Acute MI (APEX-AMI) trial. Methods: A core laboratory examined the 12-lead baseline electrocardiogram (ECG) in 5683 pts, and readers were blinded to study treatment and clinical outcomes. The association between ST-elevation (ST-E) or depression (ST-Dep) (>1mm at the J-point in lead aVR) versus no ST-deviation and 90-day death was examined via Cox regression (Hazard Ratio (HR) and 95% confidence interval (CI)), and interaction with MI location was tested. Results: Six percent (n=352) had aVR ST-E and 27% (n=1512) had aVR ST-Dep. The pts with aVR ST-E were older, higher heart rate, higher Killip class, and more prior MI compared to pts with no aVR ST-deviation (Table); they were also more likely to have a non-inferior MI. Death within 90 days was highest among those with aVR ST-E, particularly among pts with inferior MI (Table). After adjustment for age, systolic blood pressure, heart rate, creatinine, Killip class and MI location, both ST-Dep and ST-E in aVR were associated with increased hazard of 90-day death (Table). The interaction with MI location was also significant (p<0.001) such that ST-Dep was associated with higher risk in non-inferior MI pts; ST-E in aVR in inferior MI pts. Conclusions: aVR ST-deviation, occurring in one third of STEMI pts, was associated with higher 90-day death. aVR ST-Dep was most strongly associated in pts with non-inferior MI, whereas aVR ST-E was in those with inferior MI. When assessing risk from baseline ECG, the evaluation of ST-deviation in lead aVR provides valuable prognostic insight into STEMI pts treated with PCI.