Coronary Artery Disease
Prognostic Implications of Prominent R Wave in Electrocardiographic Leads V1 or V2 in Patients With Acute Coronary Syndrome

https://doi.org/10.1016/j.amjcard.2014.03.035Get rights and content

Although the adverse prognosis of Q-waves on electrocardiogram (ECG) has been demonstrated, the prognostic significance of prominent R wave (PRW) in V1 or V2 across a broad spectrum of acute coronary syndrome (ACS) has not been specifically studied. In the Global Registry of Acute Coronary Events (GRACE) and the Canadian ACS Registry I ECG substudies, admission ECGs were analyzed in an independent core ECG laboratory. PRW was defined as R wave >40 to 50 ms in V1 or V2, R/S ≥1 in V1, or R/S ≥1.5 in V2. Among 11,895 patients with ACS, 495 (4.2%) had PRW; they were less likely to have a history of hypertension or heart failure and had lower GRACE risk scores, but a higher incidence of ST-segment depression (all p ≤0.001). Patients with PRW had similar rates of in-hospital death (2.8% vs 4.1%, respectively, p = 0.15) but lower rates of in-hospital heart failure (8.5% vs 15.2%, respectively, p = 0.02) and 6-month mortality (4.6% vs 8.4%, respectively, p = 0.004). In multivariable analyses, PRW was not a significant independent predictor of in-hospital mortality (adjusted odds ratio = 0.99, 95% confidence interval 0.55 to 1.8) or 6-month mortality (adjusted odds ratio = 0.70, 95% confidence interval 0.43 to 1.15). Among 4,418 patients who underwent coronary angiography, those with PRW had a higher prevalence of left circumflex artery disease (62.5% vs 49.5%, respectively, p = 0.01). In conclusion, across the broad spectrum of patients with ACS, PRW provides no significant additional prognostic utility beyond comprehensive risk assessment using the GRACE risk score. PRW is more frequently associated with left circumflex artery disease.

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Methods

The Canadian ACS Registry I and Global Registry of Acute Coronary Events (GRACE) were prospective, multicenter, observational studies of patients admitted with ACS. The objectives and methodologies have been published previously.9, 10, 11, 12 Briefly, in the ACS I, patients ≥18 years of age with suspected acute cardiac ischemia of <24 hours of symptom onset were eligible for inclusion. In GRACE, patients had to be at least 18-year-old with a presumptive diagnosis of ACS and at least 1 of the

Results

Of the 11,895 patients in the GRACE and ACS I who had ACS and no right bundle branch block or right ventricular hypertrophy in their presenting ECG, 495 (4.2%) had PRW. Table 1 lists the baseline demographics and clinical characteristics. Figure 1 shows the location of ST-elevation on the presenting ECG.

The management and outcome during the index hospitalization and at 6 months are listed in Table 2. Figure 2 shows the angiographic findings of the 4,418 patients who underwent cardiac

Discussion

Across the broad spectrum of patients with ACS, PRW was not associated with worse outcomes. The presence of PRW was associated with lower unadjusted 6-month mortality but not in-hospital mortality. After adjusting for the established prognosticators in the GRACE risk model, PRW did not provide significant incremental prognostic value and did not improve the risk stratification of patients with ACS.

Several studies have explored the unfavorable prognosis related to posterior myocardial infarction

Acknowledgments

We are indebted to the study investigators, coordinators, and patients who participated in the ACS I and GRACE registries and to Sue Francis, BA, for her assistance in this manuscript preparation.

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Dr. Andrew Yan is supported by a New Investigator Award from the Heart and Stroke Foundation, Ottawa, Ontario, Canada. GRACE was sponsored by an unrestricted grant from Sanofi-Aventis and Bristol-Myers Squibb. The Canadian ACS Registries were sponsored by the Canadian Heart Research Center, Key Pharmaceuticals, Pfizer Canada Inc., Sanofi-Aventis Canada, and Bristol Myers Squibb Canada. The industrial sponsors had no involvement in the study conception or design; collection, analysis, and interpretation of data; in the writing, review, or approval of the manuscript; and in the decision to submit the manuscript for publication.

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