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Paradigm
Feb 28, 2017 | Bryan Wilner, MD; James A. de Lemos, MD, FACC ; Ian J. Neeland, MD
Expert Analysis
Patients with a suspected myocardial infarction (MI) in the setting of a left bundle
branch block (LBBB) present a unique diagnostic and therapeutic challenge to the
clinician. A diagnosis of MI with electrocardiogram (ECG) is especially difficult in
the setting of LBBB because of the characteristic ECG changes caused by altered
ventricular depolarization. The Sgarbossa criteria1 were first introduced over 20
years ago to improve the diagnostic accuracy for MI in the presence of LBBB;
others have subsequently modified the criteria to improve sensitivity.2 Here we
review the pathophysiology of LBBB in MI, discuss current guidelines, and
highlight evolving paradigms for the diagnosis and treatment of suspected MI in
patients with LBBB.
In contrast to the right bundle branch, the left ventricular conduction system is a
large, diffuse structure that typically requires a significant insult to result in
widespread injury. When a new LBBB is caused by MI, the infarction site is usually
anterior or anteroseptal, and the MI usually involves a large territory of
myocardium. Most cases of LBBB in suspected MI are therefore not a result of
focal infarction. Instead, extensive myocardial damage involving a large portion of
the distal conduction system is usually required to cause LBBB. This explains why
acute LBBB caused by transmural MI is associated with a poor prognosis. In rare
circumstances, acute LBBB may be caused by a more discreet MI just distal to the
bundle of His.
ST-segment concordance with the QRS complex has a specificity approaching 98%
but with limited sensitivity (~20%) (Table 1).5 Thus, the Sgarbossa criteria are
informative if present but not reassuring if absent and cannot be used to exclude
MI. In order to improve diagnostic accuracy, Smith et al.2 developed the "modified
Sgarbossa criteria," in which the original absolute 5 mm criterion is replaced with
a proportion: ST elevation/S-wave amplitude of ≤ -0.25). The authors reported
improved diagnostic sensitivity from 52 to 91% in identifying angiographically
proven MI but with reduced specificity compared with the original Sgarbossa
criteria (90 vs. 98%). The modified Sgarbossa criteria have subsequently been
validated in a separate cohort.6
Sensitivity, specificity, and positive and negative likelihood ratios are presented as summary
statistics (95% confidence intervals) for score of ≥3 and ≥2.
*ST-segment deviation is measures at the J point. Concordance and discordance of ST segments
are determined by comparison with the main direction of the QRS complex.
Overall, studies have demonstrated that less than half of all patients with
suspected MI and LBBB ultimately will be diagnosed with an MI. Moreover, a
significant proportion of those patients with MI will not have an occluded culprit
artery at catheterization and thus are classified more appropriately as having a
non-ST-
References
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart
Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and
Intervention, Noninvasive Imaging, Valvular Heart Disease, Atherosclerotic
Disease (CAD/PAD), ACS and Cardiac Biomarkers, Implantable Devices, EP Basic
Science, Acute Heart Failure, Heart Failure and Cardiac Biomarkers,
Interventions and ACS, Interventions and Coronary Artery Disease,
Interventions and Imaging, Interventions and Structural Heart Disease,
Angiography, Echocardiography/Ultrasound, Nuclear Imaging