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A shortcut review was carried out to establish whether ST elevation in aVR accurately identifies acute myocardial infarction caused by left main coronary artery stenosis. 141 unique papers were found in Medline, EMBASE, Cochrane Database of Systematic Reviews, ACP Journal Club and the Database of Abstracts of Reviews of Effects using the reported searches. Of these, 12 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is concluded that ST elevation in aVR can identify high-risk patients for early intensive investigation, particularly when found alongside widespread ST depression. It has insufficient utility to identify patients who require immediate revascularisation.

Objective: To analyse the long term prognosis in patients with isolated stenoses of the left main coronary artery (LMCA) following surgical revascularisation. Patients: 106 patients (71 men and 35 women, mean age 61 years) were operated on between 1982 and 1998. Before surgery, 103 patients presented with angina pectoris and only 10 had a history of myocardial infarction. Their mean left ventricular ejection fraction was 62%. Stenoses were localised on the LMCA ostium in 19 patients, a subgroup characterised by a high proportion of women (68%). Three patients presented with chronic LMCA occlusion. Forty six patients were operated on as an emergency. The mean (SD) number of grafts per patient was 2.0 (0.5), and only one patient had no left anterior descending (LAD) coronary artery bypass. Bypass of the LAD using the internal thoracic artery was performed in 88 cases. Results: Early postoperative mortality was 4.7% and the five year survival was 86.8%. Late mortality occurred in nine cases, and in three of these it was linked to a coronary condition. Of the 92 long term survivors, 81.5% were totally symptom-free and 77% of those of working age were able to resume work. The postoperative outcome of patients with isolated ostial LMCA stenosis did not differ significantly from that of the other patients. Conclusions: The postoperative prognosis of isolated LMCA stenosis appears good in terms of mortality and symptoms.

Objective We compared percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for the treatment of left main coronary artery (LMCA) disease by conducting a systematic review and meta-analysis of randomised controlled trials (RCTs). Methods RCTs of PCI versus CABG in patients with LMCA stenosis were identified from MEDLINE, the Cochrane Library and search of bibliographies to November 2016. Study-specific HRs with 95% CIs were aggregated for all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), and other cardiovascular events at time points of 30 days, 1 year and 3 years and beyond. Results Six RCTs comprising 4700 patients were included. There were no significant differences in risk of all-cause mortality in pooled analysis of relevant trials at 30 days (0.61, 95% CI 0.27 to 1.36), 1 year (0.66, 95% CI 0.42 to 1.04), and 3 years and beyond (1.04, 95% CI 0.81 to 1.33), comparing PCI with CABG. There was no significant difference in the risk of MACCE at 30 days (0.72, 95% CI 0.51 to 1.03) and 1 year (1.16, 95% CI 0.94 to 1.44); however, PCI was associated with a higher risk of MACCE compared with CABG during longer-term follow-up (1.27, 95% CI 1.12 to 1.44). Composite outcome of death, stroke or myocardial infarction was lower with PCI at 30 days (0.67, 95% CI 0.49 to 0.92). Repeat revascularisation was increased at 1 year and at 3 years and beyond for PCI. Conclusions All-cause mortality rates are not significantly different between PCI and CABG at short-term and long-term follow-up. However, PCI is associated with a reduction in the risk of major cardiovascular outcomes at short-term follow-up in patients with LMCA stenosis; but at long term, MACCE rate is increased for PCI., published version, peerReviewed

OBJECTIVE—To investigate the value of coronary pressure derived fractional flow reserve (FFR) measurements in supporting decisions about medical or surgical treatment in patients with angiographically equivocal left main coronary artery stenosis. DESIGN—A two centre prospective single cohort follow up study. INTERVENTIONS—FFR of the left main coronary artery was determined in 54 consecutive patients with angiographically equivocal left main coronary artery disease. If FFR was ⩾ 0.75, medical treatment was chosen; if FFR was

In the setting of acute myocardial infarction (MI) and cardiogenic shock in patients with significant unprotected left main coronary artery (LMCA) disease, treatment options are limited. In this report of a patient presenting in cardiogenic shock secondary to acute MI with critical LMCA stenosis, percutaneous coronary intervention with intra-aortic balloon pump support proved life saving.

From July 1975 to December 1977, 91 consecutive patients with left main coronary artery disease defined by cardiac catheterisation as greater than or equal to 50 per cent luminal narrowing underwent coronary bypass surgery. Prospective examination of the preoperative and postoperative clinical course of these patients was performed to determine the incidence of perioperative myocardial infarction. Intra-aortic balloon counterpulsation was instituted preoperatively in 35 patients, and these patients were classed as group A. Fifty-six patients did not receive the intra-aortic balloon pump and were classed as group B. Of 26 demographic, clinical, haemodynamic, and operative descriptors, only two were found to be significantly different between the two groups: the severity and the pattern of angina. Group A had a higher percentage of patients with class IV angina (80% vs 45%) and a greater proportion with unstable angina (37% vs 7%). Despite these differences group A patients had only a 3 per cent incidence of perioperative myocardial infraction while group B had a 23 per cent perioperative infarction rate. It is suggested that perioperative intra-aortic balloon counterpulsation can reduce the risk of perioperative myocardial infraction in patients with left main coronary artery stenosis.

We report the clinical features and the results of investigation and surgery in 20 patients with significant left main coronary artery stenosis. All had moderate to severe angina; 8 had pain at rest. Three had dyspnoea as a major symptom. The electrocardiogram was abnormal in 17, with evidence of previous myocardial infarction in 10. Of the 11 patients exercised, 8 developed chest pain. Nine patients had a normal left ventriculogram. At coronary angiography all patients had major disease elsewhere in addition to the left main coronary artery stenosis. There were no deaths or major complications associated with this investigation. One patient was unsuitable for surgery because of diffuse left ventricular hypokinesia, one had a fatal myocardial infarction while awaiting operation, and there was one preoperative death. Sixteen of the 17 surgical survivors are free from angina. There has been a significant improvement in the maximum exercise capacity in the 10 patients who had pre- and postoperative exercise tests.