MI Diagnosis in LBBB or paced rhythm

Changes in LBBB during ischemia

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

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  Case 1: 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.

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  Case 1: The same patient as in the first example 2 months before the myocardial infarction. Normal LBBB pattern.

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  Case 2: Acute MI in a patient with LBBB

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  Case 3: Acute MI in a patient with LBBB

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  Case 3: Non-ischemic ECG in this patient

References

1. 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 |
2. 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 |