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January 26, 2005

Electrocardiographic Findings in Non–ST-Segment Elevation Myocardial Infarction—Reply

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

In Reply: The Grand Rounds stated that the patient described had a high-risk electrocardiogram based on multiple leads with ST-segment depression and ST-segment elevation in lead aVR; Dr Schlegel and I agree on this. Although ST-segment elevation in aVR (with or without ST-segment elevation in V1) has been reported in acute left main and proximal left anterior descending coronary artery occlusion,1,2 it may also be an electrocardiographic presentation in patients with non–ST-segment elevation acute coronary syndromes with advanced coronary disease.1,3 Although this patient had native left-main occlusion, he had a patent left-internal mammary graft to the left anterior descending artery and, therefore, should not be considered in the same group of patients described in the literature with acute left-main occlusion. Indeed, he had normal coronary flow to the anterior wall (as well as some retrograde flow to the circumflex distribution through a diseased proximal left anterior descending artery).

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