Abstract Body: Background: ST-segment elevation in lead aVR (STE-aVR) has been associated with left main coronary artery disease or severe multivessel coronary disease in non-arrest populations. However, in patients following return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), the clinical relevance of STE-aVR remains uncertain. Post-arrest electrocardiography (ECG) findings may reflect transient global myocardial ischemia, catecholamine effects, or metabolic disturbances rather than focal coronary occlusion. This study aimed to evaluate the prevalence and diagnostic utility of STE-aVR for identifying critical coronary lesions and the need for percutaneous coronary intervention (PCI) in OHCA patients with sustained ROSC.
Methods: We conducted a retrospective analysis of adult non-traumatic OHCA patients admitted to two university-affiliated emergency departments between January 2018 and May 2023. Patients with sustained ROSC who underwent a 12-lead ECG within one hour were included. The prevalence of STE-aVR and its diagnostic performance for predicting PCI and critical coronary lesion such as 3-vessels disease or left main or proximal left anterior descending (3VD/LM/pLAD) were assessed by area under the receiver operating characteristic curve (AUC).
Results: Among 753 included patients, 121 (16.1%) exhibited STE-aVR on initial ECG. Of these, 28 patients (23.1%) underwent PCI. Among 83 patients (68.6%) who had follow-up ECGs (median time to follow-up: 66.0 minutes [IQR: 34.0–125.0]), persistent STE-aVR was observed in 35 patients (42.2%).Critical coronary lesions involving 3VD/LM/pLAD was found in 13.2% of patients with initial STE-aVR. The diagnostic performance of initial STE-aVR for predicting PCI and 3VD/LM/pLAD were poor, with an AUC of 0.495 and 0.505, respectively. Persistent STE-aVR on follow-up ECG did not significantly improve the predictive value (p=0.707 and 0.442, respectively. In patients with initial STE-aVR, PCI was independently associated with hypertension (OR = 3.73; 95%CI: 1.30-10.63), diabetes (OR = 3.30; 95%CI: 1.04-10.43), shockable rhythm (OR = 4.23; 95%CI: 1.37-13.12), and shorter cardiopulmonary resuscitation duration (OR = 0.96; 95%CI 0.93-0.99).
Conclusion: STE-aVR in initial post-ROSC ECG and persistent on follow-up ECG were not a reliable predictor of PCI or critical coronary lesions. These findings suggest STE-aVR in post-arrest ECG reflects global myocardial stress rather than focal ischemia.