The Reply

Abstract

We read with interest the letter by Kosuge and Kimura in which the issue of withholding clopidogrel in high-risk patients likely requiring coronary artery bypass grafting is discussed. We described a case of non-ST-segment elevation myocardial infarction involving the left main coronary artery presenting with diffuse ST depression and ST elevation in lead aVR.1Ching S. Ting S.M. The forgotten lead: aVR in left main disease.Am J Med. 2015; 128: e11-e13Abstract Full Text Full Text PDF Scopus (3) Google Scholar ST elevation in aVR is shown to be a reasonably sensitive and specific noninvasive marker of left main or coronary artery 3-vessel disease, but it provides no information about the “interventionability” of the lesion. In our experience, the majority of unprotected left main coronary artery can be treated with percutaneous coronary intervention safely and effectively,2Lo K.Y. Chan C.K. Characteristics and outcomes of patients with percutaneous coronary intervention for unprotected left main coronary artery disease: a Hong Kong experience.Hong Kong Med J. 2014; 20: 187-193PubMed Google Scholar as is true for multivessel disease. Therefore, adequate preprocedural clopidogrel loading is important. The decision to withhold clopidogrel or other P2Y12 inhibitors in patients with features suggestive of left main coronary artery or 3-vessel disease hinges on rapid delineation of coronary anatomy and transfer to cardiothoracic service, in order to minimize ischemic time without dual antiplatelet coverage. Essentially, it is a balance of logistics, thrombotic, and bleeding risk. Without on-site cardiothoracic support, we prefer initiating early dual antiplatelet therapy regardless of ST changes in aVR. This is in line with a position statement from the Canadian Cardiovascular Society.3Fitchett D. Eikelboom J. Fremes S. et al.Dual antiplatelet therapy in patients requiring urgent coronary artery bypass grafting surgery: a position statement of the Canadian Cardiovascular Society.Can J Cardiol. 2009; 25: 683-689Abstract Full Text PDF PubMed Scopus (65) Google Scholar Value of ST-Segment Elevation in Lead aVR for Predicting Severe Left Main or 3-Vessel DiseaseThe American Journal of MedicineVol. 129Issue 6PreviewChing and Ting1 reported the interesting case of a patient with non–ST-segment elevation acute coronary syndrome who had ST-segment elevation in lead aVR and widespread ST-segment depression in other leads on electrocardiography during chest pain. Urgent coronary angiography revealed severe left main disease extending into the proximal left anterior descending and left circumflex coronary arteries in this patient. The authors emphasized the importance of lead aVR as a predictor of severe coronary artery disease. Full-Text PDF