The prognostic value of positive T-wave in lead aVR in hemodialysis patients

Abstract

BackgroundGiven that cardiac disease is the leading cause of mortality in hemodialysis (HD) patients, identification of patients at risk for cardiac mortality is crucial. The aim of this study was to determine if positive T-wave amplitude in lead aVR (TaVR) was predictive of cardiovascular (CV) mortality and sudden cardiac death (SCD) in a group of HD patients.Methods and resultsAfter exclusion, 223 HD patients were prospectively followed-up for 25.43 ± 3.56 months. Patients were divided into TaVR negative (n = 186) and TaVR positive (n = 37) groups. Myocardial infarction, diabetes and beta-blocker therapy were more frequent in positive TaVR patients. Patients with upright TaVR were older, had higher left ventricular mass index, lower ejection fraction, higher calcium × phosphate product, higher troponin T level, higher prevalence of ST-T abnormalities, and increased width of QRS complex and QT interval, compared with patients with negative TaVR. A Kaplan–Meier analysis showed that the cumulative incidences of CV mortality as well as SCD were higher in patients with positive TaVR compared with those with negative TaVR (log-rank, p < 0.001 in both cases). A multivariate analysis selected age [hazard ratio (HR) 1.71, p < 0.001], heart rate (HR 1.42, p = 0.016), and positive TaVR (HR 2.21, p = 0.001) as well as age (HR 1.88, p < 0.001), and positive TaVR (HR 1.53, p = 0.014) as independent predictors of CV mortality and SCD, respectively.ConclusionIn HD patients, positive TaVR is an independent and powerful predictor of CV mortality as well as SCD. This simple ECG parameter provides additional information beyond what is available with other known traditional risk factors and allows the identification of patients most at risk of CV events.

T-wave reversal in the augmented unipolar right arm electrocardiographic lead is associated with increased risk of sudden death

“…Like other studies that found a high prevalence of multi-vessel disease and old MI [20–22] in patients with a positive T wave in lead aVR, we also found old infarcts to be more prevalent in those with a positive/flat T wave in lead aVR. Our findings support the hypothesis that old infarcts or ischemia likely lead to repolarization abnormalities and contribute to arrhythmogenic substrates, linking a positive/flat T wave in aVR and SCD risk.…”

“…Few other studies have reported an association between a positive/flat T wave in lead aVR and overall cardiovascular mortality [17,18, 23]. Studies in specific populations, including: heart failure patients with narrow QRS complexes [19], hemodialysis patients [20], women [24], anterior wall STEMI patients undergoing primary PCI [21], and those with a prior myocardial infarction [25], also found a positive/flat T wave in lead aVR to be associated with increased risk of mortality.…”

Impact of T wave amplitude in lead aVR on predicting cardiac events in ischemic and nonischemic cardiomyopathy patients with an implantable cardioverter defibrillator

“…An upright T wave (TAaVR > 0 mV) is generally accepted to be a useful ECG parameter for cardiac events in males, in patients following a myocardial infarction, and in hemodialysis patients (Jaroszyński et al, 2015;Tan et al, 2008;Torigoe et al, 2012). However, high-risk patients were appropriately excluded when the cut-off value was set at −0.1 mV, as was done in the present study and as was shown in previous studies (Okuda et al, 2011).…”

“…Although the lead aVR is often neglected in daily clinical practice, ST elevation in lead aVR has been reported to be useful in the prediction of left main trunk involvement in ischemic heart disease and aortic dissection (Kireyev, Arkhipov, Zador, Paris, & Boden, 2010;Riera et al, 2011;Yan et al, 2007). Similarly, there is an increasing notion that T wave amplitude in the lead aVR (TAaVR) >0 mV (known as upright T wave) may be used as a prognostic tool in patients with postmyocardial infarction, in those with renal failure who undergo hemodialysis, and in male patients (Jaroszyński et al, 2015;Tan, Engel, Myers, Sandri, & Froelicher, 2008;Torigoe et al, 2012). However, few reports have demonstrated the ability of TAaVR to predict cardiac events, including MVAE and HHF in ICM and NICM patients with ICD.…”

Association of Lead aVR T‐wave Amplitude With Cardiovascular Events or Mortality Among Prevalent Dialysis Patients

“…In non‐CKD patients, positive T‐wave of aVR (aVRT) or amplitude of the aVRT wave was significantly associated with sudden death or CV mortality . Recently, in dialysis patients, positive aVRT was also associated with all‐cause mortality , CV related mortality or sudden death . These two studies treated aVRT wave in only two ways, positive or negative.…”