Last week there was a heated debate in our CCU regarding thrombolysis for a patient with severe rest angina and ST elevation in AVR and ST depression in V2-V5 as it implies Left main disease Few argued left main disease is an exception where one can thrombolyse even with unstable angina !
One of my fellows argued ACC guidelines vouched for lysis in UA involving left main .( I do not agree )
A logical attempt to differentiate Left main NSTEMI//UA and STEMI
(In the strict sense Left main NSTEMI is misnomer as AVR shows ST elevation isn’t ? )
Final message
Such patients with suspected LMD are to be rushed to cath lab . . . agreed . If it is not feasible , manage it as high risk unstable angina and do not thrombolyse .Let it be left main disease . Indications for lysis are clear. ST elevation in AVR alone can not be taken as an Indication for lysis.For thromolysis to be effective there should be high thrombus burden with total occlusion . ST elevation in single lead (AVR ) is not a good marker for left-main thrombus !
Dr.S.Venkatesan MD 
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