Clopidogrel should be initiated as soon as possible in patients with non–ST-segment
elevation acute coronary syndrome (NSTE-ACS) except those who urgently require coronary
artery bypass grafting (CABG). The present study assessed the ability to predict severe
left main coronary artery and/or 3-vessel disease (LM/3VD) that would most likely
require urgent CABG based on only clinical factors on admission in 572 patients with
NSTE-ACS undergoing coronary angiography. Severe LM/3VD was defined as ≥75% stenosis
of LM and/or 3VD with ≥90% stenosis in ≥2 proximal lesions of the left anterior descending
coronary artery and other major epicardial arteries. Patients were divided into the
3 groups according to angiographic findings: no LM/3VD (n = 460), LM/3VD but not severe
LM/3VD (n = 57), and severe LM/3VD (n = 55). Severe LM/3VD was associated with a higher
rate of urgent CABG compared to no LM/3VD and LM/3VD but not severe LM/3VD (46%, 2%,
and 2%, p <0.001). On multivariate analysis, degree of ST-segment elevation in lead
aVR was the strongest predictor of severe LM/3VD (odds ratio 29.1, p <0.001), followed
by positive troponin T level (odds ratio 1.27, p = 0.044). ST-segment elevation ≥1.0
mm in lead aVR best identified severe LM/3VD with 80% sensitivity, 93% specificity,
56% positive predictive value, and 98% negative predictive value. In conclusion, ST-segment
elevation ≥1.0 mm in lead aVR on admission electrocardiogram is highly suggestive
of severe LM/3VD in patients with NSTE-ACS. Selected patients with this finding might
benefit from promptly undergoing angiography, withholding clopidogrel to allow early
CABG.
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Article Info
Publication History
Published online: December 24, 2010
Accepted:
October 1,
2010
Received in revised form:
October 1,
2010
Received:
August 28,
2010
Identification
Copyright
© 2011 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
