Comparison of the Prognostic Effect of Left Versus Right Versus No Bundle Branch Block on Presenting Electrocardiogram in Acute Myocardial Infarction Patients Treated With Primary Angioplasty in the Primary Angioplasty in Myocardial Infarction Trials

Guerrero, Mayra; Harjai, Kishore J.; Stone, Gregg W.; Brodie, Bruce R.; Cox, David A.; Boura, Judy; Grines, Lorelei; O’Neill, William W.; Grines, Cindy L.

doi:10.1016/j.amjcard.2005.04.006

Cited by 55 publications

(43 citation statements)

References 26 publications

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“…Of particular interest is that the 30-day mortality was remarkably higher in the patients with ECG expression of complete BBB than in those without even undergoing primary PCI. Therefore, the findings of the current study, in addition to reinforcing those of the previous studies, 6,7,22,23) highlight the important role of new-onset CLBBB and CRBBB in predicting unfavorable clinical outcomes for AMI patients.…”

Section: Discussionsupporting

confidence: 86%

“…22,23) However, whether new-onset CLBBB or CRBBB after AMI in the modern reperfusion era (ie, by means of primary PCI) is still an important predictor of untoward clinical outcome has not been fully studied. 6,7) One important finding in the present study is that patients with ECG presentation of either CLBBB or CRBBB had significantly higher incidences of advanced Killip score upon presentation, advanced CHF, higher peak serum CPK level, and more severe LV dysfunction compared with those without these ECG findings. Of particular interest is that the 30-day mortality was remarkably higher in the patients with ECG expression of complete BBB than in those without even undergoing primary PCI.…”

Section: Discussionsupporting

confidence: 50%

“…Our findings were consistent with those from previous studies. 6,7,22) Second, the current study showed that lower R-wave voltage of precordial leads 24 hours after AMI was strongly associated with poorer LVEF, higher peak serum CPK level, increased incidence of advanced Killip core, and more advanced CHF. Third, of importance was the fact that change of R-wave voltage in V 1 -V 6 was strongly and independently predictive of 30-day MACE in patients with AMI undergoing primary PCI.…”

Section: Discussionmentioning

confidence: 54%

“…[2][3][4][5] Some distinctive ECG findings, including new onset of complete left bundle branch block (CLBBB), 6) combined expression of pathological Q-wave and complete right bundle branch block (CRBBB), 7) ST-segment elevation ≥ 1 mV in aVR lead, 8) inferior wall myocardial infarction (MI) complicated by right ventricular infarction, 9) and simultaneous inferior wall and anterior wall ST-segment elevation, 10) have been shown to be useful ECG features for the prediction of prognosis after acute myocardial infarction (AMI). Recently, the resolution of elevated ST-segments in patients with acute ST-elevation MI (STEMI) undergoing primary percutaneous coronary intervention (PCI) has also been identified as an important marker of ECG for assessing left ventricular (LV) function and prognostic outcome.…”

mentioning

confidence: 99%

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Prognostic Value of R-Wave Voltage in Patients With Anterior Wall ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

et al. 2010

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SummaryThe prognostic value of integrated R-wave voltages of precordial leads (V 1 -V 6 ) in patients with acute anterior wall ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) was investigated.Between July 2006 and October 2009, 292 patients with anterior wall STEMI with presentation < 12 hours underwent primary PCI. Thirty-four patients with electrocardiographic presentation of either complete right bundle branch block (BBB) or complete left BBB were categorized into group A, while the remaining 258 patients without BBB served as group B that was further subdivided into those with lower R-wave voltage (summation of V 1 -V 6 ≤ 1.7 mV) (group 1) and higher voltage (> 1.7 mV) (group 2) according to the ROC curve (sensitivity = 66.3%, specificity = 66%, P < 0.0001).While the procedural success rate was similar between groups A and B and groups 1 and 2, 30-day mortality was higher in group A than B (P ≤ 0.0001). Additionally, left ventricular ejection fraction (LVEF) was lower, whereas peak level of creatine phosphopkinase (CPK), incidence of advanced congestive heart failure, and 30-day mortality were higher in group 1 than 2 (P < 0.01). Multivariate analysis revealed that lower R-wave voltage, multivessel disease, leukocyte count, peak CPK, and creatinine level were predictive of 30-day unfavorable clinical outcomes (all P < 0.01). Rwave voltage in precordial leads was a significant independent predictor of 30-day prognostic outcome in patients with anterior wall STEMI undergoing primary PCI. (Int Heart J 2010; 51: 325-330) Key words: Electrocardiogram, Acute myocardial infarction, R-wave voltage, 30-day major adverse cardiac events I t is well known that the electrocardiogram (ECG), which was first developed more than 100 years ago, 1) is a useful noninvasive tool for the diagnosis of various cardiac disorders in daily clinical practice.2-5) Some distinctive ECG findings, including new onset of complete left bundle branch block (CLBBB), 6) combined expression of pathological Q-wave and complete right bundle branch block (CRBBB), 7) ST-segment elevation ≥ 1 mV in aVR lead, 8) inferior wall myocardial infarction (MI) complicated by right ventricular infarction, 9) and simultaneous inferior wall and anterior wall ST-segment elevation, 10) have been shown to be useful ECG features for the prediction of prognosis after acute myocardial infarction (AMI). Recently, the resolution of elevated ST-segments in patients with acute ST-elevation MI (STEMI) undergoing primary percutaneous coronary intervention (PCI) has also been identified as an important marker of ECG for assessing left ventricular (LV) function and prognostic outcome.11-13) Baseline Q waves 14,15) in STEMI patients treated with primary PCI have also been reported to be an independent prognostic marker of clinical outcome.Although the peak serum level of creatinine phosphokinase, 16) myocardial thallium scan, 17) and the evaluation of LV function using transthoracic echocardiography 18) are all useful t...

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Section: Discussionsupporting

confidence: 86%

Section: Discussionsupporting

confidence: 50%

Section: Discussionmentioning

confidence: 54%

mentioning

confidence: 99%

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Prognostic Value of R-Wave Voltage in Patients With Anterior Wall ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

et al. 2010

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“…In several studies on chronic and acute CAD, LBBB was found to be an excellent predictor of mortality and events [20][21][22][23][24] (Table 2). In 681 patients with acute myocardial infarction (AMI) enrolled in the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) 9 and Global Utilization of Streptokinase and t-PA for Occluded Arteries (GUSTO) 1 protocols, 25 the incidence of LBBB was found to be 7%.…”

Section: Left Bundle-branch Block and Risk Stratification In Heart DImentioning

confidence: 99%

Left bundle‐branch block—pathophysiology, prognosis, and clinical management

Francia

Balla

Paneni

et al. 2007

Clinical Cardiology

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Summary: Given its broad use as a screening tool, the electrocardiogram (ECG) has largely become one of the most common diagnostic tests performed in routine clinical practice. As a result, the finding of left bundle-branch block (LBBB) in the absence of a well-defined clinical setting has become relatively frequent and raises questions and often concerns. While in the absence of clinically detectable heart disease LBBB does not necessarily imply poor outcomes, physicians should be aware of the role of LBBB in stratifying risk of cardiovascular events and death in subjects with both ischemic and nonischemic heart disease. This paper reviews historical landmarks, pathophysiologic features, prognostic implications, and clinical management of LBBB in apparently healthy subjects and those with heart disease. Evolving Concepts, Misunderstandings, and Current Appraisal of Left Bundle-Branch BlockAs early as the beginning of the past century, Eppinger and Tothberger, by means of a rudimental but efficient experimental model, performed experiments destroying pieces of dog myocardium by injecting silver nitrate and then observing the induced electrocardiographic (ECG) changes. 1 By means of a single esophageal-anal lead, these and other investigators found that injuring the left and right bundle branches resulted, respectively, in an upward and a downward QRS deflection on ECG. 2 Ironically, the mere extrapolation of data obtained from this experimental canine model resulted in a 25-year misunderstanding of the real electrical abnormalities. Left bundle-branch block (LBBB) pattern was incorrectly identified as right bundle-branch block (RBBB), and vice versa. In fact, since the esophageal-anal lead was erroneously judged to be "vertical" in the dog, the presence in humans of a wide downward deflection in leads II and III was considered to disclose RBBB. 3 Almost 70 years after elucidation of this long-lasting misinterpretation, the electrogenesis and ECG pattern of LBBB appear to be fully clarified. Under normal conditions, the electrical impulse from the His bundle passes through a narrow anterior fascicle, a broader early branching posterior fascicle, and a third septal segment composed of many branches originating from each of the fascicles. The electrical impulse then spreads through a rich peripheral Purkinje network that couples with individual myocardial cells. 4,5 The simultaneous electrical activation of the right ventricle from its own branch results in the QRS complex, which then represents the "sum" of two parallel and independent electrical phenomena. Left bundle-branch block completely modifies the electrical activation of the left ventricle and QRS complex on ECG. The activation of the interventricular septum, which is left-sided in physiologic conditions, originates on its right side. The electrical impulse propagates then inferiorly, to the left, and slightly anteriorly. This results in a nonhomogeneous and delayed depolarization of the left ventricle, which can be only partially preserved in the presen...

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