Letter to the Editor—Krishnaswamy response to Fiol
Article Outline
Author's Reply:
We read the response to our article titled “Magnitude and consequences of missing the acute infarct-related circumflex artery”1 with great interest. The goal of our article was to highlight the missed opportunities for acute reperfusion in contemporary clinical practice. The American College of Cardiology and American Health Association as well as organizations around the world have rightfully committed significant monetary resources as well as human capital to enhancing optimal reperfusion for patients with ST-segment elevation myocardial infarction on presenting electrocardiogram (EKG). By highlighting the weakness of the conventional EKG to detect epicardial occlusion in this vulnerable group of patients we seek to encourage systems of myocardial infarction care to use novel diagnostic and treatment protocols in this patient population. One such EKG-based strategy is highlighted by Fiol et al.2 Their sequential strategy has a sensitivity of 80% with a specificity of 100% to identify the occluded circumflex artery. Unfortunately, all steps in this process require the presence of ST elevation on the surface EKG and, although useful to identify the culprit infarct-related artery, would likely result in prompt activation of the acute reperfusion system. Our data highlight the current experience in multiple large-scale clinical trials and suggest that the prevalence and consequences of missing the occluded circumflex are not inconsequential. In current practice activation of the reperfusion system is performed by the emergency physician or the first response team based on the presenting or prehospital EKG. Obtaining leads V7 to V9 can certainly increase the yield, but these data are not new, appear seldom used, and the diagnostic problem at hand persists. We discuss the role of a sophisticated surface body mapping technique for completeness in the context of a review, but the unique color display systems may have significant potential in the hands of a noncardiologist to enhance recognition and system activation in the setting of an acute posterior circulation coronary occlusion. The merits of this approach however remain unproven and need to be evaluated in a rigorous fashion.
References
- . Magnitude and consequences of missing the acute infarct-related circumflex artery. Am Heart J. 2009;158:706–712
- Value of electrocardiographic algorithm based on “ups and downs” of ST in assessment of a culprit artery in evolving inferior wall acute myocardial infarction. Am J Cardiol. 2004;94:709–714
PII: S0002-8703(10)00318-2
doi:10.1016/j.ahj.2010.04.002
© 2010 Mosby, Inc. All rights reserved.
Refers to article:
- Magnitude and consequences of missing the acute infarct-related circumflex artery , 25 September 2009
- Letter to the Editor Re: Krishnaswamy
