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Affiliation(s)
- Chuan-Hai Zhang
- Department of Cardiology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning, China
| | - Ting-Ting Li
- Department of Cardiology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, Liaoning, China
| | - Xiaohong Chen
- Department of Emergency, The Third People's Hospital of Chengdu, The Affiliated Hospital of Southwest Jiaotong University, Chengdu, Sichuan, China
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Khawaja M, Thakker J, Kherallah R, Ye Y, Smith SW, Birnbaum Y. Diagnosis of Occlusion Myocardial Infarction in Patients with Left Bundle Branch Block and Paced Rhythms. Curr Cardiol Rep 2021; 23:187. [PMID: 34791609 DOI: 10.1007/s11886-021-01613-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW A number of criteria have been developed to aid with the diagnosis of occlusion myocardial infarction (OMI) in patients with left bundle branch block (LBBB) and ventricular paced rhythms (VPR). The current guidelines do not provide clear preference for any specific ECG criteria in LBBB and paced rhythm patients. RECENT FINDINGS This review delineates the difficulties of electrocardiographic diagnosis of OMI in both LBBB and VPR patients. We describe the original Sgarbossa and the newer criteria and their diagnostic performances. We highlight the expected changes of newer pacing modalities and how they may interfere with the electrocardiographic diagnosis of OMI. We recommend utilizing the Cai et al. algorithm, which combines clinical assessment with the Smith Modified Sgarbossa ECG criteria, for both LBBB and right ventricular pacing patients with suspected OMI. There is limited data concerning ECG changes of OMI in patients with the newer pacing modalities, such as biventricular, His-bundle, or left bundle branch pacing.
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Affiliation(s)
- Muzamil Khawaja
- Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Janki Thakker
- Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Riyad Kherallah
- Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Yumei Ye
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare and the University of Minnesota School of Medicine, 701 S. Park Ave. Minneapolis, Minnesota, MN, 55415, USA.
| | - Yochai Birnbaum
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, MS: BCM620. One Baylor Plaza, Houston, TX, 77030, USA.
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Di Marco A, Rodriguez M, Cinca J, Bayes-Genis A, Ortiz-Perez JT, Ariza-Solé A, Sanchez-Salado JC, Sionis A, Rodriguez J, Toledano B, Codina P, Solé-González E, Masotti M, Gómez-Hospital JA, Cequier Á, Anguera I. New Electrocardiographic Algorithm for the Diagnosis of Acute Myocardial Infarction in Patients With Left Bundle Branch Block. J Am Heart Assoc 2020; 9:e015573. [PMID: 32627643 PMCID: PMC7660719 DOI: 10.1161/jaha.119.015573] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Current electrocardiographic algorithms lack sensitivity to diagnose acute myocardial infarction (AMI) in the presence of left bundle branch block. Methods and Results A multicenter retrospective cohort study including consecutive patients with suspected AMI and left bundle branch block, referred for primary percutaneous coronary intervention between 2009 and 2018. Pre‐2015 patients formed the derivation cohort (n=163, 61 with AMI); patients between 2015 and 2018 formed the validation cohort (n=107, 40 with AMI). A control group of patients without suspected AMI was also studied (n=214). Different electrocardiographic criteria were tested. A total of 484 patients were studied. A new electrocardiographic algorithm (BARCELONA algorithm) was derived and validated. The algorithm is positive in the presence of ST deviation ≥1 mm (0.1 mV) concordant with QRS polarity, in any lead, or ST deviation ≥1 mm (0.1 mV) discordant with the QRS, in leads with max (R|S) voltage (the voltage of the largest deflection of the QRS, ie, R or S wave) ≤6 mm (0.6 mV). In both the derivation and the validation cohort, the BARCELONA algorithm achieved the highest sensitivity (93%–95%), negative predictive value (96%–97%), efficiency (91%–94%) and area under the receiver operating characteristic curve (0.92–0.93), significantly higher than previous electrocardiographic rules (P<0.01); the specificity was good in both groups (89%–94%) as well as the control group (90%). Conclusions In patients with left bundle branch block referred for primary percutaneous coronary intervention, the BARCELONA algorithm was specific and highly sensitive for the diagnosis of AMI, leading to a diagnostic accuracy comparable to that obtained by ECG in patients without left bundle branch block.
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Affiliation(s)
- Andrea Di Marco
- Heart Disease Institute Bellvitge University Hospital Barcelona Spain
| | - Marcos Rodriguez
- Heart Disease Institute Bellvitge University Hospital Barcelona Spain
| | - Juan Cinca
- Cardiology Department Hospital de la Santa Creu I Sant Pau IIB-Santpau CIBERCV Universitat Autonoma de Barcelona Spain
| | - Antoni Bayes-Genis
- Cardiology Department Germans Trias i Pujol University Hospital CIBERCV Badalona Spain
| | | | - Albert Ariza-Solé
- Heart Disease Institute Bellvitge University Hospital Barcelona Spain
| | | | - Alessandro Sionis
- Cardiology Department Hospital de la Santa Creu I Sant Pau IIB-Santpau CIBERCV Universitat Autonoma de Barcelona Spain
| | - Jany Rodriguez
- Cardiology Department Hospital Clinic CIBERCV Barcelona Spain
| | - Beatriz Toledano
- Cardiology Department Germans Trias i Pujol University Hospital CIBERCV Badalona Spain
| | - Pau Codina
- Cardiology Department Germans Trias i Pujol University Hospital CIBERCV Badalona Spain
| | - Eduard Solé-González
- Cardiology Department Hospital de la Santa Creu I Sant Pau IIB-Santpau CIBERCV Universitat Autonoma de Barcelona Spain
| | - Monica Masotti
- Cardiology Department Hospital Clinic CIBERCV Barcelona Spain
| | | | - Ángel Cequier
- Heart Disease Institute Bellvitge University Hospital Barcelona Spain
| | - Ignasi Anguera
- Heart Disease Institute Bellvitge University Hospital Barcelona Spain
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Lai YC, Chen YH, Wu KH, Chen YC. Validation of the diagnosis and triage algorithm for acute myocardial infarction in the setting of left bundle branch block. Am J Emerg Med 2020; 38:2614-2619. [PMID: 32245703 DOI: 10.1016/j.ajem.2020.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/06/2020] [Accepted: 03/15/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Detecting acute ST-segment elevation myocardial infarction (STEMI) in the setting of left bundle branch block (LBBB) remains a challenge to clinicians. Several diagnostic and triage algorithms have been proposed to accurately identify LBBB patients with an acute culprit vessel. We aimed to validate the algorithm proposed by Cai et al., which uses patients' hemodynamic status and the modified Sgarbossa electrocardiography criteria to guide reperfusion therapy. METHODS This retrospective study was performed with a chart review in emergency departments (EDs) of 2 medical centers, 2 regional hospitals, and 1 local hospital. From January 2010 to December 2014, 2432 consecutive patients were diagnosed as having STEMI in the ED, including 65 patients with LBBB (2.6%). RESULTS The patients with LBBB were older and more frequently presented with acute pulmonary edema (58.5% vs 22.1%, p < 0.001), cardiogenic shock (16.9% vs 6.3% p = 0.006), and VT/VF episodes (7.7% vs 2.2%, p = 0.034) and had a higher 30-day mortality rate (20.0% vs 10.4% p = 0.032) than those without LBBB. We then tested the algorithm proposed by Cai et al. and noted a sensitivity of 93.8% in identifying a culprit lesion. CONCLUSIONS The inconsistency of the guideline recommendations reflects the uncertainty of diagnostic and therapeutic strategies and the pressing need for tools to accurately identify the true acute myocardial infarction in patients presenting with chest pain and LBBB. The algorithm proposed by Cai et al. had good sensitivity and would allow emergency physicians to implement the timely treatment protocol for this high-risk population.
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Affiliation(s)
- Yi-Chen Lai
- Department of Emergency Medicine, An Nan Hospital, China Medical University, Tainan, Taiwan
| | - Yu-Han Chen
- Department of Family Medicine, Chi-Mei Medical Center, No.901, Zhonghua Rd., Yongkang Dist., Tainan City 710, Taiwan
| | - Kai-Hsiang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan
| | - Yi-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, No.6, W. Sec., Jiapu Rd., Puzih City, Chiayi County 613, Taiwan; Chang Gung University College of Medicine, No.5, Fusing St., Gueishan Township, Taoyuan County 333, Taiwan.
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Tzimas G, Antiochos P, Monney P, Eeckhout E, Meier D, Fournier S, Harbaoui B, Muller O, Schläpfer J. Atypical Electrocardiographic Presentations in Need of Primary Percutaneous Coronary Intervention. Am J Cardiol 2019; 124:1305-1314. [PMID: 31455501 DOI: 10.1016/j.amjcard.2019.07.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/30/2019] [Accepted: 07/02/2019] [Indexed: 11/19/2022]
Abstract
Early initiation of reperfusion therapy remains the cornerstone of successful management for ST-elevation myocardial infarction (STEMI). Rapid restoration of coronary blood flow relies on prompt recognition of the typical ST-segment elevation on a 12-lead electrocardiogram (ECG)-a surrogate for coronary occlusion or critical stenosis-allowing timely activation of the STEMI protocol cascade, with a major positive impact in mortality and clinical outcomes. However, atypical, very high risk ECG patterns-known as "STEMI equivalents"-are present in 10% to 25% of patients with ongoing myocardial ischemia in need of urgent primary percutaneous coronary intervention. Though briefly mentioned in the current recommendations, structured clinical data on those specific ECG presentations are lacking. By thoroughly searching MEDLINE and EMBASE we conducted a structured review of non-STEMI, albeit very high risk, ECG patterns of acute coronary syndrome, often associated with coronary occlusion or critical stenosis. After screening 997 studies, we identified the following distinct "STEMI equivalent" ECG patterns: Wellens' syndrome, de Winter sign, hyperacute T waves, left bundle branch block-including paced rhythm-and right bundle branch block. For each pattern, a brief summary of the existing evidence, together with the sensitivity, specificity, and positive predictive value-whenever available-are presented. In conclusion, prompt recognition of "STEMI equivalent" ECG patterns is crucial for every physician or paramedic dealing with acute coronary syndrome patients in the emergency department or the prehospital setting, as misinterpretation of those high risk presentations can lead to reperfusion delays and worse outcomes.
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Affiliation(s)
- Georgios Tzimas
- Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland.
| | - Panagiotis Antiochos
- Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Pierre Monney
- Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Eric Eeckhout
- Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - David Meier
- Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Stephane Fournier
- Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Brahim Harbaoui
- University Hospital la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Olivier Muller
- Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Jürg Schläpfer
- Department of Cardiology, University Hospital of Lausanne, Lausanne, Switzerland
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Falsos positivos en las redes de atención al IAMCEST: un peaje inevitable. Rev Esp Cardiol (Engl Ed) 2018. [DOI: 10.1016/j.recesp.2017.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Barrabés JA, Sambola A. False-positive Activations in STEMI Networks: An Unavoidable Toll. ACTA ACUST UNITED AC 2018; 71:234-236. [PMID: 29307465 DOI: 10.1016/j.rec.2017.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 10/06/2017] [Indexed: 11/28/2022]
Affiliation(s)
- José A Barrabés
- Unidad Coronaria, Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CIBERCV, Barcelona, Spain.
| | - Antonia Sambola
- Unidad Coronaria, Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CIBERCV, Barcelona, Spain
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