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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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Steven P. Schulman, MD
sschulm@jhmi.edu
Coronary Care Unit
The Johns Hopkins Hospital
Baltimore, MD

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