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Alshaikh LM, Apple FS, Christenson RH, deFilippi CR, Limkakeng AT, McCord J, Nowak RM, Singer AJ, Peacock WF. Outcomes in ED patients with non‐specific ECG findings and low high‐sensitivity troponin. J Am Coll Emerg Physicians Open 2022; 3:e12844. [PMID: 36408352 PMCID: PMC9669988 DOI: 10.1002/emp2.12844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 08/13/2022] [Accepted: 09/16/2022] [Indexed: 11/18/2022] Open
Abstract
Background Although some emergency department risk stratification tools consider non‐specific ECG findings as an aid in disposition decisions, their clinical value in patients with an initially low high‐sensitivity cardiac troponin I (hsTnI) is unclear. Objective Our purpose was to determine if non‐specific ECG (ns‐ECG) findings are associated with 30‐day major adverse cardiac events (MACE) in ED patients presenting with suspected acute coronary syndromes (ACS) who have a low initial hsTnI. Methods Using the prospective Siemens Atellica hsTnI Food and Drug Administration submission observational database, we conducted a retrospective cohort study of the association between ns‐ECG findings (defined as left bundle branch block [LBBB], ST depression [STD], or T‐wave inversions [TWI]) and 30‐day MACE (death, myocardial infarction, heart failure hospitalization, or coronary revascularization). Eligible patients presented with suspected ACS to one of 29 US EDs from April 2015 to April 2016, had stable vital signs, a blood sample for hsTnI (Siemen's Atellica, Siemens Healthineers, Inc, Malvern, PA) obtained at 1, 3, and 6 hours after ED presentation, and were followed for 30 days. The relationship between 30‐day outcome, initial hsTnI, and ns‐ECG was evaluated using chi‐square testing. Results Of 2676 enrolled, 1313 patients met the inclusion criteria and are included in the analysis. Median (interquartile range) age was 62 years (54, 72), 54% were male, with 56% white, and 39% African American. Median (interquartile range) times from symptom onset to presentation and presentation to specimen collection were 92 (0, 216) and 146 (117, 177) minutes, respectively. The most common presenting symptoms were chest pain (84%), followed by dyspnea (9%). ECG findings were categorized as T‐wave inversion or non‐specific T wave changes (42%), ST depression ns‐ECG ST changes (16%), or LBBB (2%). Thirty‐day MACE occurred in 72 (5.5%) patients, with coronary revascularization (35 patients, 2.7%) and heart failure (25 patients, 1.9%) being the most frequent outcomes. In patients with an initial hsTnI below the limit of quantitation (LOQ) of 2.5 ng/L (n = 449), there was no association between ns‐ECG changes and 30‐day MACE (P = 0.42). If the hsTnI was ≥LOQ (2.5 ng/L), there were increased rates of 30‐day MACE and ns‐ECG findings (P = 0.01). Conclusion In ED suspected ACS patients without unstable vital signs, and an initial hsTnI less than the LOQ (2.5 ng/L), ns‐ECG findings are not associated with 30‐day major adverse cardiac events. The use of ns‐ECG findings in ACS disposition should be considered in the context of hsTnI levels.
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Affiliation(s)
| | - Fred S. Apple
- Hennepin County Medical Center University of Minnesota Minneapolis Minnesota USA
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Davis P, Howie GJ, Dicker B, Garrett NK. Paramedic-Delivered Fibrinolysis in the Treatment of ST-Elevation Myocardial Infarction: Comparison of a Physician-Authorized versus Autonomous Paramedic Approach. PREHOSP EMERG CARE 2019; 24:617-624. [PMID: 31718381 DOI: 10.1080/10903127.2019.1683661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: For those patients who receive fibrinolysis in the treatment of ST-elevation myocardial infarction (STEMI), early treatment, i.e., within 2 hours of symptom onset, confers the greatest clinical benefit. This rationale underpins paramedic-delivered fibrinolysis in the prehospital setting. However, the current New Zealand approach requiring paramedics to first gain physician authorization, has proved inefficient and time consuming, particularly due to technological failings. Therefore, this study aimed to trial a new autonomous paramedic-delivered fibrinolysis model, examining the impact on time-to-treatment, paramedic diagnostic accuracy and patient outcomes. Methods: Utilizing a prospective observational approach, over a 24-month period, paramedics identified patients with a clinical presentation and electrocardiogram features consistent with STEMI, and initiated fibrinolysis. These patients were compared to a historic cohort who received fibrinolysis by paramedics within the same regions but following physician authorization. The main outcome measures were pain-to-needle (PTN) time and accuracy of paramedic diagnosis. A secondary end-point was 30-day and 6-month mortality and hospital length of stay (LOS). Results: A total of 174 patients received fibrinolysis (mean age, 64 years, SD ± 11.2). Median PTN time was 87 minutes (IQR = 58) for the historic cohort (n = 96), versus 65 minutes (IQR = 31) for the experimental cohort (n = 78), (p = 0.007). Autonomous paramedic diagnosis showed a sensitivity of 96% (95% CI 89-99) and specificity of 91% (95% CI 76-98). A significant reduction in both 30-day mortality and hospital LOS was observed among the experimental cohort (p = 0.04 and <0.001, respectively). No significant difference was observed between groups in terms of 6-month mortality. Conclusions: Prehospital fibrinolysis provided autonomously by paramedics without direct physician oversight is safe and feasible. Moreover, this independent approach can significantly improve time-to-treatment, resulting in short term mortality benefit and reduced hospital LOS.
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Glass G, O’Connor R, Brady WJ. Useful addition to acute myocardial infarction diagnosis in patients with left bundle branch block: an algorithm using electrocardiographic and biomarker analysis. BRITISH HEART JOURNAL 2019; 105:1530-1532. [DOI: 10.1136/heartjnl-2019-315380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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4
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Davis P, Howie GJ, Dicker B, Garrett NK. Paramedic-initiated helivac to tertiary hospital for primary percutaneous coronary intervention: a strategy for improving treatment delivery times. J Thorac Dis 2019; 11:1819-1830. [PMID: 31285874 DOI: 10.21037/jtd.2019.05.45] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background In regions of New Zealand without coronary catheterisation laboratory (CCL) facilities, patients presenting with ST-elevation myocardial infarction (STEMI) are often subjected to prolonged delays before receiving primary percutaneous coronary intervention (PPCI) if it is the chosen reperfusion strategy. Therefore, we aimed to trial a new process of paramedic-initiated helivac of STEMI patients from the field directly to the CCL. Methods Utilising a prospective observational approach, over a 48-month period, paramedics identified patients with a clinical presentation and electrocardiogram features consistent with STEMI and transported them directly to the regional air ambulance base for helivac to the CCL (flight time 30-35 minutes). These patients were compared to two historic STEMI cohorts either transported by paramedics to the region's local hospital or self-presenting, prior to helivac. The primary outcome measures were: first medical contact-to-balloon (FMCTB) time and accuracy of paramedic diagnosis. Secondary outcome measures were mortality at 30 days and six months, and hospital length of stay (LOS). Results A total of 92 patients underwent helivac for PPCI (mean age of 64 years, SD ±10.3). Median FMCTB time was 155 minutes (IQR 27) for the historic cohorts (n=57), versus 102 minutes (IQR 16) for the experimental cohort (n=35, P<0.001). Paramedic diagnosis showed a sensitivity of 97% (95% CI: 85 to 99) and a specificity of 100% (95% CI: 84 to 100) with no inappropriate CCL activations. No significant difference was observed between groups in terms of 30 day and 6-month mortality. Hospital LOS was significantly shorter among the experimental cohort (P=0.01). Conclusions Paramedic-initiated helivac of STEMI patients from the field directly to the CCL for PPCI is safe and feasible and can significantly improve time-to-treatment to within benchmark timeframes, resulting in reduced hospital LOS.
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Affiliation(s)
- Paul Davis
- Clinical Audit and Research Team, St John Ambulance Service, Auckland, New Zealand.,Department of Paramedicine, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Graham J Howie
- Department of Paramedicine, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Bridget Dicker
- Clinical Audit and Research Team, St John Ambulance Service, Auckland, New Zealand.,Department of Paramedicine, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Nicholas K Garrett
- Biostatistics and Epidemiology, Faculty of Health and Environmental Science, Auckland University of Technology, Auckland, New Zealand
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Nestelberger T, Cullen L, Lindahl B, Reichlin T, Greenslade JH, Giannitsis E, Christ M, Morawiec B, Miro O, Martín-Sánchez FJ, Wussler DN, Koechlin L, Twerenbold R, Parsonage W, Boeddinghaus J, Rubini Gimenez M, Puelacher C, Wildi K, Buerge T, Badertscher P, DuFaydeLavallaz J, Strebel I, Croton L, Bendig G, Osswald S, Pickering JW, Than M, Mueller C. Diagnosis of acute myocardial infarction in the presence of left bundle branch block. Heart 2019; 105:1559-1567. [PMID: 31142594 DOI: 10.1136/heartjnl-2018-314673] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 05/01/2019] [Accepted: 05/08/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Patients with suspected acute myocardial infarction (AMI) in the setting of left bundle branch block (LBBB) present an important diagnostic and therapeutic challenge to the clinician. METHODS We prospectively evaluated the incidence of AMI and diagnostic performance of specific ECG and high-sensitivity cardiac troponin (hs-cTn) criteria in patients presenting with chest discomfort to 26 emergency departments in three international, prospective, diagnostic studies. The final diagnosis of AMI was centrally adjudicated by two independent cardiologists according to the universal definition of myocardial infarction. RESULTS Among 8830 patients, LBBB was present in 247 (2.8%). AMI was the final diagnosis in 30% of patients with LBBB, with similar incidence in those with known LBBB versus those with presumably new LBBB (29% vs 35%, p=0.42). ECG criteria had low sensitivity (1%-12%) but high specificity (95%-100%) for AMI. The diagnostic accuracy as quantified by the receiver operating characteristics (ROC) curve of hs-cTnT and hs-cTnI concentrations at presentation (area under the ROC curve (AUC) 0.91, 95% CI 0.85 to 0.96 and AUC 0.89, 95% CI 0.83 to 0.95), as well as that of their 0/1-hour and 0/2-hour changes, was very high. A diagnostic algorithm combining ECG criteria with hs-cTnT/I concentrations and their absolute changes at 1 hour or 2 hours derived in cohort 1 (45 of 45(100%) patients with AMI correctly identified) showed high efficacy and accuracy when externally validated in cohorts 2 and 3 (28 of 29 patients, 97%). CONCLUSION Most patients presenting with suspected AMI and LBBB will be found to have diagnoses other than AMI. Combining ECG criteria with hs-cTnT/I testing at 0/1 hour or 0/2 hours allows early and accurate diagnosis of AMI in LBBB. TRIAL REGISTRATION NUMBER APACE: NCT00470587; ADAPT: ACTRN12611001069943; TRAPID-AMI: RD001107;Results.
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Affiliation(s)
- Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Louise Cullen
- Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Bertil Lindahl
- Department of Cardiology, University Hospital Uppsala, Uppsala, Sweden
| | - Tobias Reichlin
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Jaimi H Greenslade
- Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | | | - Michael Christ
- Department of Emergency Medicine, Luzerner Kantonsspital, Luzern, Switzerland
| | - Beata Morawiec
- Department of Cardiology, University Hospital, Zabrze, Poland
| | - Oscar Miro
- Department of Emergency Department, Hospital Clinic, Barcelona, Spain
| | | | - Desiree Nadine Wussler
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - William Parsonage
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Maria Rubini Gimenez
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Tobias Buerge
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Jeanne DuFaydeLavallaz
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Lukas Croton
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Garnet Bendig
- Roche Forschungs-, Entwicklungs- und Produktionszentrum, Penzberg, Germany
| | - Stefan Osswald
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | | | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
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Leonardi S, Bueno H, Ahrens I, Hassager C, Bonnefoy E, Lettino M. Optimised care of elderly patients with acute coronary syndrome. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 7:287-295. [DOI: 10.1177/2048872618761621] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Sergio Leonardi
- Fondazione IRCCS Policlinico S. Matteo, Coronary Care Unit, Pavia, Italy
| | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain
- Instituto de investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Spain
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Germany
- Faculty of Medicine, University of Freiburg, Germany
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Eric Bonnefoy
- Intensive Cardiac Care Unit, Hospices Civils de Lyon, France
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7
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How to best use high-sensitivity cardiac troponin in patients with suspected myocardial infarction. Clin Biochem 2018; 53:143-155. [DOI: 10.1016/j.clinbiochem.2017.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 12/15/2017] [Indexed: 11/21/2022]
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8
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Managing chest pain in patients with concomitant left bundle-branch block. JAAPA 2017; 30:16-21. [DOI: 10.1097/01.jaa.0000525904.44484.5c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Twerenbold R, Boeddinghaus J, Nestelberger T, Wildi K, Rubini Gimenez M, Badertscher P, Mueller C. Clinical Use of High-Sensitivity Cardiac Troponin in Patients With Suspected Myocardial Infarction. J Am Coll Cardiol 2017; 70:996-1012. [DOI: 10.1016/j.jacc.2017.07.718] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/09/2017] [Accepted: 07/10/2017] [Indexed: 12/12/2022]
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10
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Al Rajoub B, Noureddine S, El Chami S, Haidar MH, Itani B, Zaiter A, Akl EA. The prognostic value of a new left bundle branch block in patients with acute myocardial infarction: A systematic review and meta-analysis. Heart Lung 2017; 46:85-91. [DOI: 10.1016/j.hrtlng.2016.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/10/2016] [Accepted: 11/11/2016] [Indexed: 10/20/2022]
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11
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Pera VK, Larson DM, Sharkey SW, Garberich RF, Solie CJ, Wang YL, Traverse JH, Poulose AK, Henry TD. New or presumed new left bundle branch block in patients with suspected ST-elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:208-217. [PMID: 29064258 DOI: 10.1177/2048872617691508] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AIMS Using a comprehensive large prospective regional ST-elevation myocardial infarction (STEMI) system database, we evaluated the prevalence, clinical and angiographic characteristics, and outcomes in patients with ischemic symptoms and new or presumed new left bundle branch block (LBBB). We then tested a new hierarchical diagnosis and triage algorithm to identify more accurately new LBBB patients with an acute culprit lesion. METHODS AND RESULTS From March 2003 to June 2013, 3903 consecutive STEMI patients were treated using the Minneapolis Heart Institute regional STEMI protocol including 131 patients (3.3%) with new LBBB. These patients had fewer culprit arteries (54.2% vs. 86.4%; P<0.001), were older, more commonly women, with a lower ejection fraction, and more frequently presented with cardiac arrest or heart failure than those without new LBBB. At 1 year follow-up, all-cause mortality accounting for baseline differences was higher in patients with new LBBB (hazard ratio 1.73, 95% confidence interval 1.17-2.58; P=0.007). The new algorithm yielded high sensitivity (97%) and negative predictive value (94%) for identification of a culprit lesion. Using the definition of new LBBB with either hemodynamically unstable features or Sgarbossa concordance criteria on electrocardiogram (ECG), 45% of new LBBB patients would have been treated as 'STEMI equivalent'. CONCLUSION Patients with acute ischemic symptoms and new LBBB represent a high-risk population with unique clinical challenges. If validated in an independent dataset, the new algorithm may improve the diagnostic accuracy regarding reperfusion therapy for new LBBB patients.
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Affiliation(s)
- Vijaya K Pera
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - David M Larson
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Scott W Sharkey
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Ross F Garberich
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Christopher J Solie
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Yale L Wang
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Jay H Traverse
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Anil K Poulose
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA
| | - Timothy D Henry
- 1 Division of Cardiology, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, USA.,2 Division of Cardiology, Cedars-Sinai Heart Institute, USA
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Lambert LJ, Brophy JM, Racine N, Rinfret S, L'Allier PL, Brown KA, Boothroyd LJ, Ross D, Segal E, Kouz S, Maire S, Harvey R, Kezouh A, Nasmith J, Bogaty P. Outcomes of Patients With ST-Elevation Myocardial Infarction Receiving and Not Receiving Reperfusion Therapy: The Importance of Examining All Patients. Can J Cardiol 2016; 32:1325.e11-1325.e18. [DOI: 10.1016/j.cjca.2016.02.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/29/2016] [Indexed: 10/22/2022] Open
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von Jeinsen B, Tzikas S, Pioro G, Palapies L, Zeller T, Bickel C, Lackner KJ, Baldus S, Blankenberg S, Muenzel T, Zeiher AM, Keller T. Troponin I Assay for Identification of a Significant Coronary Stenosis in Patients with Suspected Acute Myocardial Infarction and Wide QRS Complex. PLoS One 2016; 11:e0154724. [PMID: 27148734 PMCID: PMC4858235 DOI: 10.1371/journal.pone.0154724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 04/18/2016] [Indexed: 12/02/2022] Open
Abstract
Background Common ECG criteria such as ST-segment changes are of limited value in patients with suspected acute myocardial infarction (AMI) and bundle branch block or wide QRS complex. A large proportion of these patients do not suffer from an AMI, whereas those with ST-elevation myocardial infarction (STEMI) equivalent AMI benefit from an aggressive treatment. Aim of the present study was to evaluate the diagnostic information of cardiac troponin I (cTnI) in hemodynamically stable patients with wide QRS complex and suspected AMI. Methods In 417 out of 1818 patients presenting consecutively between 01/2007 and 12/2008 in a prospective multicenter observational study with suspected AMI a prolonged QRS duration was observed. Of these, n = 117 showed significant obstructive coronary artery disease (CAD) used as diagnostic outcome variable. cTnI was determined at admission. Results Patients with significant CAD had higher cTnI levels compared to individuals without (median 250ng/L vs. 11ng/L; p<0.01). To identify patients needing a coronary intervention, cTnI yielded an area under the receiver operator characteristics curve of 0.849. Optimized cut-offs with respect to a sensitivity driven rule-out and specificity driven rule-in strategy were established (40ng/L/96ng/L). Application of the specificity optimized cut-off value led to a positive predictive value of 71% compared to 59% if using the 99th percentile cut-off. The sensitivity optimized cut-off value was associated with a negative predictive value of 93% compared to 89% provided by application of the 99th percentile threshold. Conclusion cTnI determined in hemodynamically stable patients with suspected AMI and wide QRS complex using optimized diagnostic thresholds improves rule-in and rule-out with respect to presence of a significant obstructive CAD.
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Affiliation(s)
- Beatrice von Jeinsen
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- * E-mail: (TK); (BJ)
| | - Stergios Tzikas
- 3rd Department of Cardiology, Aristotle University of Thessaloniki, Ippokrateio Hospital, Thessaloniki, Greece
- Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Gerhard Pioro
- Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Lars Palapies
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Christoph Bickel
- Department of Internal Medicine, Federal Armed Forces Hospital, Koblenz, Germany
| | - Karl J. Lackner
- Department of Laboratory Medicine, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Stephan Baldus
- Department of Internal Medicine III, University of Cologne, Köln, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Thomas Muenzel
- Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Andreas M. Zeiher
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Till Keller
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
- * E-mail: (TK); (BJ)
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14
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Meyers HP, Limkakeng AT, Jaffa EJ, Patel A, Theiling BJ, Rezaie SR, Stewart T, Zhuang C, Pera VK, Smith SW. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study. Am Heart J 2015; 170:1255-64. [PMID: 26678648 DOI: 10.1016/j.ahj.2015.09.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 09/10/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The modified Sgarbossa criteria were proposed in a derivation study to be superior to the original criteria for diagnosing acute coronary occlusion (ACO) in left bundle branch block (LBBB). The new rule replaces the third criterion (5 mm of excessively discordant ST elevation [STE]) with a proportion (at least 1 mm STE and STE/S wave ≤-0.25). We sought to validate the modified criteria. METHODS This retrospective case-control study was performed by chart review in 2 tertiary care center emergency departments (EDs) and 1 regional referral center. A billing database was used at 1 site to identify all ED patients with LBBB and ischemic symptoms between May 2009 and June 2012. In addition, all 3 sites identified LBBB ACO patients who underwent emergent catheterization. We measured QRS amplitude and J-point deviation in all leads, blinded to outcomes. Acute coronary occlusion was determined by angiographic findings and cardiac biomarker levels, which were collected blinded to electrocardiograms. Diagnostic statistics of each rule were calculated and compared using McNemar's test. RESULTS Our consecutive cohort search identified 258 patients: 9 had ACO, and 249 were controls. Among the 3 sites, an additional 36 cases of ACO were identified, for a total of 45 ACO cases and 249 controls. The modified criteria were significantly more sensitive than the original weighted criteria (80% vs 49%, P < .001) and unweighted criteria (80% vs 56%, P < .001). Specificity of the modified criteria was not statistically different from the original weighted criteria (99% vs 100%, P = .5) but was significantly greater than the original unweighted criteria (99% vs 94%, P = .004). CONCLUSIONS The modified Sgarbossa criteria were superior to the original criteria for identifying ACO in LBBB.
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15
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Comparison of clinical characteristics and outcomes in patients with left bundle branch block versus ST-elevation myocardial infarction referred for primary percutaneous coronary intervention. Coron Artery Dis 2015; 26:17-21. [PMID: 25076359 DOI: 10.1097/mca.0000000000000156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIMS Recent studies have suggested that a low proportion of patients presenting with left bundle branch block (LBBB) require emergency intervention. In this study, we have compared baseline clinical characteristics, angiographic findings and subsequent outcomes in patients with LBBB versus ST-elevation myocardial infarction (STEMI) referred to our tertiary centre for primary percutaneous coronary intervention (PCI). METHODS AND RESULTS A large retrospective observational study was performed involving 1875 consecutive patients presenting to our single tertiary cardiac centre for primary PCI over a 27-month period. Patients presenting with LBBB (n=155, 8.3%) were significantly older (P<0.0001) and were more likely to be female (P<0.0001) and have a prior history of myocardial infarction (P<0.0001) or coronary artery bypass graft surgery (P=0.005). Rates of acute occlusion (12.2 vs. 63%; P<0.0001) and PCI (26 vs. 83%; P<0.0001) were significantly lower in LBBB patients compared with STEMI patients. Although the 30-day mortality was similar, overall mortality during the 2 years of follow-up was significantly higher in the LBBB group compared with the STEMI group (27.8 vs. 13.9%; P=0.023). CONCLUSION The incidence of an acutely occluded vessel is low in LBBB when compared with STEMI, but the long-term outcome is significantly worse. Patients with LBBB referred for primary PCI need better risk stratification, and further work is needed to identify potential diagnostic and management strategies.
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Affiliation(s)
- Konstantinos C. Koskinas
- First Cardiology Department, AHEPA Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Antonios Ziakas
- First Cardiology Department, AHEPA Hospital, Aristotle University Medical School, Thessaloniki, Greece
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Liakopoulos V, Kellerth T, Christensen K. Left bundle branch block and suspected myocardial infarction: does chronicity of the branch block matter? EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 2:182-9. [PMID: 24222829 DOI: 10.1177/2048872613483589] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 03/02/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Our aim was to investigate if patients with suspected myocardial infarction (MI) and a new or presumed new left bundle branch block (nLBBB) were treated according to the ESC reperfusion guidelines and to compare them with patients having a previously known LBBB (oLBBB). Furthermore, we investigated the prevalence of ST-segment concordance in this population. METHODS Retrospective data was collected from the Swedeheart registry for patients admitted to the cardiac care unit at Örebro University Hospital with LBBB and suspected MI during 2009 and 2010. The patients were divided in two age groups; <80 or ≥80 years and analysed for LBBB chronicity (nLBBB or oLBBB), MI, and reperfusion treatment. We also compared our data with the national Swedeheart database for 2009. RESULTS A total of 99 patients fulfilled the inclusion criteria. A diagnosis of MI was significantly more common in the group ≥80 years compared to the group <80 years (53.8 vs. 25%, p=0.007). The rate of MI was similar in the groups with nLBBB and oLBBB (33 and 37% respectively, p=0.912). Of the 36 patients with a final diagnosis of MI, only eight (22%) had nLBBB. Reperfusion treatment, defined as an acute coronary angiography with or without intervention, was significantly more often performed in patients with nLBBB compared to patients with oLBBB (42 vs. 8%, p<0.001). The rate of MI and reperfusion treatment did not differ between our institution and the Swedish national data. ST-concordance was present in only two cases, one of which did not suffer an MI. CONCLUSIONS The proportion of patients receiving reperfusion treatment was low, but higher in nLBBB, reflecting a partial adherence to the guidelines. We found no correlation between LBBB chronicity and MI. Furthermore, only a minority of the MIs occurred in patients with nLBBB. ST-concordance was found in only one of 36 MI cases, indicating lack of sensitivity for this test.
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New ST-segment elevation myocardial infarction criteria for left bundle branch block based on QRS area. J Electrocardiol 2013; 46:528-34. [DOI: 10.1016/j.jelectrocard.2013.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Indexed: 11/22/2022]
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Taboulet P, Smith SW, Brady WJ. Diagnostic ECG du syndrome coronarien aigu. ANNALES FRANCAISES DE MEDECINE D URGENCE 2013. [DOI: 10.1007/s13341-012-0272-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kumar V, Venkataraman R, Aljaroudi W, Osorio J, Heo J, Iskandrian AE, Hage FG. Implications of left bundle branch block in patient treatment. Am J Cardiol 2013; 111:291-300. [PMID: 23111137 DOI: 10.1016/j.amjcard.2012.09.029] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Revised: 09/01/2012] [Accepted: 09/01/2012] [Indexed: 11/27/2022]
Abstract
Left bundle branch block (LBBB) causes an abnormal pattern of cardiac activation and affects regional myocardial function. Although recognition of LBBB on the surface electrocardiogram is straightforward, dissecting its effect on patient treatment and outcome can be more challenging. The altered pattern of cardiac activation in LBBB causes electrical and mechanical ventricular dyssynchrony, influences ischemia detection on the surface electrocardiogram, and affects stress testing and imaging modalities dependent on wall motion and thickening. Restoration of synchrony by biventricular pacing can improve symptoms and longevity in carefully selected patients. The diagnostic, prognostic, and therapeutic implications of LBBB across this spectrum are discussed in this review.
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Smith SW. Updates on the Electrocardiogram in Acute Coronary Syndromes. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2012. [DOI: 10.1007/s40138-012-0003-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Smith SW, Dodd KW, Henry TD, Dvorak DM, Pearce LA. Diagnosis of ST-Elevation Myocardial Infarction in the Presence of Left Bundle Branch Block With the ST-Elevation to S-Wave Ratio in a Modified Sgarbossa Rule. Ann Emerg Med 2012; 60:766-76. [DOI: 10.1016/j.annemergmed.2012.07.119] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Revised: 07/20/2012] [Accepted: 07/24/2012] [Indexed: 12/12/2022]
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Neeland IJ, Kontos MC, de Lemos JA. Evolving considerations in the management of patients with left bundle branch block and suspected myocardial infarction. J Am Coll Cardiol 2012; 60:96-105. [PMID: 22766335 DOI: 10.1016/j.jacc.2012.02.054] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 02/17/2012] [Accepted: 02/27/2012] [Indexed: 01/09/2023]
Abstract
Patients with a suspected acute coronary syndrome and left bundle branch block (LBBB) present a unique diagnostic and therapeutic challenge to the clinician. Although current guidelines recommend that patients with new or presumed new LBBB undergo early reperfusion therapy, data suggest that only a minority of patients with LBBB are ultimately diagnosed with acute myocardial infarction, regardless of LBBB chronicity, and that a significant proportion of patients will not have an occluded culprit artery at cardiac catheterization. The current treatment approach exposes a significant proportion of patients to the risks of fibrinolytic therapy without the likelihood of significant benefit and leads to increased rates of false-positive cardiac catheterization laboratory activation, unnecessary risks, and costs. Therefore, alternative strategies to those for patients with ST-segment elevation myocardial infarction are needed to guide selection of appropriate patients with a suspected acute coronary syndrome and LBBB for urgent reperfusion therapy. In this article, we describe the evolving epidemiology of LBBB in acute coronary syndromes and discuss controversies related to current clinical practice. We propose a more judicious diagnostic approach among clinically stable patients with LBBB who do not have electrocardiographic findings highly specific for ST-segment elevation myocardial infarction.
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Affiliation(s)
- Ian J Neeland
- Donald W. Reynolds Cardiovascular Clinical Research Center, Dallas, TX, USA
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Mehta N, Huang HD, Bandeali S, Wilson JM, Birnbaum Y. Prevalence of acute myocardial infarction in patients with presumably new left bundle-branch block. J Electrocardiol 2012; 45:361-367. [PMID: 22575807 DOI: 10.1016/j.jelectrocard.2012.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Indexed: 01/13/2023]
Abstract
OBJECTIVES We assessed the prevalence of true acute myocardial infarction and the need for emergent revascularization among patients with new or presumably new left bundle branch block (nLBBB) for whom the primary percutaneous coronary intervention protocol was activated. METHODS AND RESULTS Among 802 patients, 69 (8.6%) had nLBBB. The chief presenting symptom was chest pain or cardiac arrest in 36 patients (52.2%) and shortness of breath in 15 (21.7%). Less than 30% of the patients had elevated cardiac troponin-I, and less than 10% had elevated creatine kinase-MB. Only 11.6% of the patients underwent emergent revascularization; the rate was higher for patients who presented with chest pain or cardiac arrest or shortness of breath than for patients who presented with other symptoms. CONCLUSIONS Acute myocardial infarction and the need for emergent revascularization are relatively uncommon among patients who present with nLBBB, especially when symptoms are atypical. Current guidelines for primary percutaneous coronary intervention protocol activation for nLBBB should be reconsidered.
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Affiliation(s)
- Nilay Mehta
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX
| | - Henry D Huang
- Section of Cardiology, Baylor College of Medicine, Houston, TX
| | - Salman Bandeali
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - James M Wilson
- Section of Cardiology, Baylor College of Medicine, Houston, TX; Department of Cardiology, the Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, TX
| | - Yochai Birnbaum
- Section of Cardiology, Baylor College of Medicine, Houston, TX; Department of Cardiology, the Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, TX.
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Smith SW, Dodd KW. Letter to the editor regarding "Outcomes in patients with chronicity of left bundle-branch block with possible acute myocardial infarction". Am Heart J 2011; 162:e23. [PMID: 21982675 DOI: 10.1016/j.ahj.2011.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rokos IC, Farkouh ME, Reiffel J, Dressler O, Mehran R, Stone GW. Correlation between index electrocardiographic patterns and pre-intervention angiographic findings: Insights from the HORIZONS-AMI trial. Catheter Cardiovasc Interv 2011; 79:1092-8. [DOI: 10.1002/ccd.23262] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Accepted: 05/28/2011] [Indexed: 11/10/2022]
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