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January 26, 2005

Electrocardiographic Findings in Non–ST-Segment Elevation Myocardial Infarction

JAMA. 2005;293(4):423-424. doi:10.1001/jama.293.4.423-a

To the Editor: In the Grand Rounds on antiplatelet therapy in non–ST-segment elevation myocardial infarction,1 Dr Schulman describes a patient with findings that seem inconsistent with this diagnosis. The patient’s electrocardiogram had ST-segment elevation in lead aVR. Although this was noted to be suggestive of inferior and lateral ischemia and an independent risk factor for in-hospital death, Schulman does not consider the significance of the concomitant smaller 1 mm ST-segment elevation in lead V1. The combination of ST-segment elevations in aVR and V1, with the former being larger than the latter, is a marker of proximal left main coronary artery occlusion.2 Indeed, this patient’s angiogram showed just such a stenosis. Therefore, the patient does not fall into the conventional non–ST-segment elevation myocardial infarction population in that multiple territories were at risk. I believe that it would have been more appropriate for him to have been triaged for rapid angiographic evaluation instead of coronary care unit admission and treatment with multiple antiplatelet agents. While there is strong evidence supporting use of clopidogrel in non–ST-segment elevation myocardial infarction,3 its use in ST-segment elevation myocardial infarction remains an open question.4,5

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