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Percutaneous coronary intervention and coronary artery bypass grafting are two methods for treating patients with extensive coronary artery disease (CAD). Choosing method of treatment is difficult for both physicians and patients. European guidelines recommend multidisciplinary decision-making when choosing which procedure to utilize. The purpose of this local quality improvement study was to examine how patients with extensive CAD, defined as stenosis in the three major coronary arteries or in the main stem of two coronary arteries, were treated in Uppsala University Hospital during 2020. We found that 29 out of 95 patients were treated without previous multidisciplinary discussions, but plausible reasons for this were found in the medical records of 26 out of 29 patients. How these patients should be treated in regards to guidelines, efficient use of resources, and informed consent is a difficult task. We hope to raise a discussion of how these patients are treated in other hospitals.

During four decades, the ECG limb lead display has differed between Sweden and the rest of the world. In the classical, or international, display, the limb leads are presented in two groups in non-contiguous order: I, II, III, and aVR, aVL, aVF. When ECG recording and presentation was standardized in Sweden, a joint decision between several medical specialty associations was made to use the so-called Cabrera presentation, in which limb leads are presented in contiguous order: aVL, I, -aVR, II, aVF and III. This presentation is logical and easily understood.

Patients with unstable coronary artery disease have a serious but variable prognosis. An early and specific prediction of risk is essential for stratification of treatment. Serum was obtained at a median of 9.5 hours from symptom onset in 7800 patients with unstable coronary artery disease included in the GUSTO-IV trial for analyses of creatinine, troponin-T, C-reactive protein (CRP) and N-terminal pro brain natriuretic peptide (NT-proBNP). Quartiles of troponin-T were related to an increased mortality and to an increased incidence of myocardial infarction. Increasing quartiles of C-reactive protein were also related to an increased mortality but there was no relation to the incidence of myocardial infarction. On multivariate analysis, troponin-T was the strongest marker for prediction of myocardial infarction, but reduced creatinine clearance and ST-depression at admission were also significant predictors. Prediction of subsequent mortality was possible with several risk indicators. Elevation of NT-proBNP was the strongest predictor of short and long-term mortality with a continuous increase in one-year mortality in relation to the levels. Also reduced creatinine clearance, elevation of CRP, troponin-T, ST-depression and clinical factors indicating a history of cardiovascular disease provided independent prognostic information on long-term mortality. A multimarker strategy with creatinine clearance, troponin, CRP and NT-proBNP together with ischemic ECG changes and clinical background characteristics provides the best prognostic information for choice of treatment in patients with unstable coronary artery disease.