MI Diagnosis in LBBB or paced rhythm: Difference between revisions
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Revision as of 08:48, 8 October 2009
In case of a left bundle branch block (LBBB), infarct diagnosis based on the ECG is difficult. The baseline ST segments and T waves tend to be shifted in a discordant direction with LBBB, which can mask or mimic acute myocardial infarction. However, serial ECGs may show a moving ST segment during ischemia secondary to dynamic supply versus demand characteristics. A new LBBB is always pathological and can be a sign of myocardial infarction. The criteria (Sgarbossa [1]) that can be used in case of a LBBB and suspicion of infarction are:
- ST elevation > 1mm in leads with a positive QRS complex (concordance in ST deviation) (score 5)
- ST depression > 1 mm in V1-V3 (concordance in ST deviation) (score 3)
- ST elevation > 5 mm in leads with a negative QRS complex (inappropriate discordance in ST deviation) (score 2). This criterium is sensitive, but not specific for ischemia in LBBB. It is however associated with a worse prognosis, when present in LBBB during ischemia.[2]
At a score-sum of 3, these criteria have a specificity of 90% for detecting a myocardial infarction.
Examples
Acute myocardial infarction in in a patient with a pacemaker and LBBB. Concordant ST elevation in V5-V6 are clearly visible. There is discordant ST segment elevation > 5 mm in lead V3.
The same patient as in the first example 2 months before the myocardial infarction. Normal LBBB pattern.
Acute MI in a patient with LBBB
References
- Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, Gates KB, Topol EJ, Califf RM, and Wagner GS. 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. N Engl J Med. 1996 Feb 22;334(8):481-7. DOI:10.1056/NEJM199602223340801 |
- Wong CK, French JK, Aylward PE, Stewart RA, Gao W, Armstrong PW, Van De Werf FJ, Simes RJ, Raffel OC, Granger CB, Califf RM, White HD, and HERO-2 Trial Investigators. Patients with prolonged ischemic chest pain and presumed-new left bundle branch block have heterogeneous outcomes depending on the presence of ST-segment changes. J Am Coll Cardiol. 2005 Jul 5;46(1):29-38. DOI:10.1016/j.jacc.2005.02.084 |