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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 . . . [Full Text of this Article]

Amnon Schlegel, MD, PhD
aschlege@itsa.ucsf.edu
Department of Medicine
Division of Endocrinology
University of California, San Francisco

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