ELECTROCARDIOGRAPHIC DIAGNOSIS OF MYOCARDIAL INFARCTION IN PATIENTS WITH LEFT BUNDLE BRANCH BLOCK.

Li SF, et al. Ann Emerg Med 2000 Dec;36(6):561-5.

STUDY OBJECTIVE: To validate ECG criteria previously proposed by Sgarbossa et al for the detection of myocardial infarction (MI) in patients with left bundle branch block (LBBB) and suspected ischemia.

METHODS: A retrospective cohort study was performed at an urban teaching hospital. All patients admitted with suspected ischemia and LBBB were eligible. MI was defined as an elevated creatine kinase (CK) isoenzyme MB (>14 IU/L) that was at least 5% of total CK level. ECGs were interpreted by 2 physicians blinded to patient outcome. Interpreters were asked to rate ECGs for the presence of each of the 3 criteria proposed by Sgarbossa et al: (1) ST-segment elevation greater than or equal to 1 mm concordant with the QRS complex; (2) ST-segment elevation greater than or equal to 5 mm discordant with the QRS complex; and (3) ST-segment depression in leads V(1) through V(3). Interobserver agreement was assessed.

RESULTS: Of 190 eligible patients, 25 (13%) had MI. Sensitivities of the 3 criteria varied from 0 to 16%, with specificities of 93% to 100%. Only the first criterion demonstrated a clinically useful likelihood ratio (positive likelihood ratio=16 [95% confidence interval 4 to >100]). Patients with new LBBB were more likely to have MI (relative risk=5. 1 [95% confidence interval 2.6 to 10]). Interobserver agreement among ECG interpreters ranged from 93% to 98%.

CONCLUSION: The criteria of Sgarbossa et al cannot be used to exclude MI in patients with LBBB because of low sensitivities and poor negative likelihood ratios. ST-segment elevation concordant with the QRS complex had a high positive likelihood ratio for identification of MI. Patients with new LBBB and suspected ischemia are 5 times more likely to have MI than patients with LBBB of chronic or unknown duration.

SHOULD THE ELECTROCARDIOGRAM BE USED TO GUIDE THERAPY FOR PATIENTS WITH LEFT BUNDLE-BRANCH BLOCK AND SUSPECTED MYOCARDIAL INFARCTION?

Shlipak MG, et al. JAMA 1999 Feb 24;281(8):714-9.

CONTEXT: Recently, an algorithm based on the electrocardiogram (ECG) was reported to predict myocardial infarction (MI) in patients with left bundle-branch block (LBBB), but the clinical impact of this testing strategy is unknown.

OBJECTIVE: To determine the diagnostic test characteristics and clinical utility of this ECG algorithm for patients with suspected MI. DESIGN: Retrospective cohort study to which an algorithm was applied, followed by decision analysis regarding thrombolysis made with or without the algorithm.

SETTING: University emergency department, 1994 through 1997.

PATIENTS: Eighty-three patients with LBBB who presented 103 times with symptoms suggestive of MI.

MAIN OUTCOME MEASURES: Myocardial infarction determined by serial cardiac enzyme analyses and stroke-free survival.

RESULTS: Of 9 ECG findings assessed, none effectively distinguished the 30% of patients with MI from those with other diagnoses. The ECG algorithm indicated positive findings in only 3% of presentations and had a sensitivity of 10% (95% confidence interval, 2%-26%). The decision analysis showed that among 1000 patients with LBBB and chest pain, 929 would survive without major stroke if all received thrombolysis compared with 918 if the ECG algorithm was used as a screening test.

CONCLUSIONS: The ECG is a poor predictor of MI in a community-based cohort of patients with LBBB and acute cardiopulmonary symptoms. Acute thrombolytic therapy should be considered for all patients with LBBB who have symptoms consistent with MI.

ELECTROCARDIOGRAPHIC DIAGNOSIS OF EVOLVING ACUTE MYOCARDIAL INFARCTION IN THE PRESENCE OF LEFT BUNDLE-BRANCH BLOCK. GUSTO-1 (GLOBAL UTILIZATION OF STREPTOKINASE AND TISSUE PLASMINOGEN ACTIVATOR FOR OCCLUDED CORONARY ARTERIES) INVESTIGATORS.

Sgarbossa EB, et al. N Engl J Med 1996 Feb 22;334(8):481-7.

BACKGROUND. The presence of left bundle-branch block on the electrocardiogram may conceal the changes of acute myocardial infarction, which can delay both its recognition and treatment. We tested electrocardiographic criteria for the diagnosis of acute infarction in the presence of left bundle-branch block.

METHODS. The base-line electrocardiograms of patients enrolled in the GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) trial who had left bundle-branch block and acute myocardial infarction confirmed by enzyme studies were blindly compared with the electrocardiograms of control patients who had chronic coronary artery disease and left bundle-branch block. The electrocardiographic criteria for the diagnosis of infarction were then tested in an independent sample of patients presenting with acute chest pain and left bundle-branch block.

RESULTS. Of 26,003 North American patients, 131 (0.5 percent) with acute myocardial infarction had left bundle-branch block. The three electrocardiographic criteria with independent value in the diagnosis of acute infarction in these patients were an ST-segment elevation of 1 mm or more that was concordant with (in the same direction as) the QRS complex; ST-segment depression of 1 mm or more in lead V1, V2, or V3; and ST-segment elevation of 5 mm or more that was disconcordant with (in the opposite direction from) the QRS complex. We used these three criteria in a multivariate model to develop a scoring system (0 to 10), which allowed a highly specific diagnosis of acute myocardial infarction to be made.

CONCLUSIONS. We developed and validated a clinical prediction rule based on a set of electrocardiographic criteria for the diagnosis of acute myocardial infarction in patients with chest pain and left bundle-branch block. The use of these criteria, which are based on simple ST-segment changes, may help identify patients with acute myocardial infarction, who can then receive appropriate treatment.