title: An early and simple predictor of severe left main and/or three-vessel disease in patients with non-ST-segment elevation acute coronary syndrome.
abstract: 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.
authors.affiliation: Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan. masami-kosuge@pop06.odn.ne.jp
authors.forename: Masami
authors.initials: M
authors.lastname: Kosuge
authors.forename: Toshiaki
authors.initials: T
authors.lastname: Ebina
authors.forename: Kiyoshi
authors.initials: K
authors.lastname: Hibi
authors.forename: Satoshi
authors.initials: S
authors.lastname: Morita
authors.forename: Mitsuaki
authors.initials: M
authors.lastname: Endo
authors.forename: Nobuhiki
authors.initials: N
authors.lastname: Maejima
authors.forename: Noriaki
authors.initials: N
authors.lastname: Iwahashi
authors.forename: Kozo
authors.initials: K
authors.lastname: Okada
authors.forename: Toshiyuki
authors.initials: T
authors.lastname: Ishikawa
authors.forename: Satoshi
authors.initials: S
authors.lastname: Umemura
authors.forename: Kazuo
authors.initials: K
authors.lastname: Kimura
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000473:pathology* / Q000503:physiopathology / Q000628:therapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D000077144:Clopidogrel; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000473:pathology; D042241:Early Diagnosis; D004562:Electrocardiography; D005260:Female; D006329:Heart Conduction System / Q000503:physiopathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D016896:Treatment Outcome; D020107:Troponin T / Q000097:blood
chemical_list: D015415:Biomarkers; D010975:Platelet Aggregation Inhibitors; D020107:Troponin T; D000077144:Clopidogrel; D013988:Ticlopidine