Electrocardiographic Diagnosis of Evolving Acute Myocardial Infarction in the Presence of Left Bundle-Branch Block

Sgarbossa, Elena B.; Pinski, Sergio L.; Barbagelata, Alejandro; Underwood, Donald A.; Gates, Kathy; Topol, Eric J.; Califf, Robert M.; Wagner, Galen S.

doi:10.1056/nejm199602223340801

Cited by 563 publications

(194 citation statements)

References 45 publications

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“…5 The presence of an LBBB can obscure the diagnosis of acute ST-T elevation myocardial infarction. 6 However, the modest elevation in the level of troponin I, the lack of akinesis of wall segments, the normal findings on coronary angiography, and the absence of delayed contrast enhancement by magnetic resonance imaging allowed the exclusion of an acute myocardial infarction as the cause of acute heart failure in this patient.…”

Section: Discussionmentioning

confidence: 78%

Acute Heart Failure Due to Transient Left Ventricular Dyssynchrony: Case Study

Jourdain

Bauchart

Auffray

et al. 2010

American Journal of Critical Care

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This case study describes an unusual cause of acute heart failure that resolved with early beta-blockade therapy. A 52-year-old woman who had acute heart failure with severe left ventricular systolic dysfunction and left bundle branch block was admitted to a university medical center. Contrast-enhanced magnetic resonance images of the heart did not show any evidence of myocardial infarction or myocarditis. Rate-related left bundle branch block and subsequent left ventricular dyssynchrony resulted in acute systolic dysfunction that resolved with beta-blockade therapy that allowed heart rate control and narrowing of the QRS complex. Of note, the use of inotropic agents would have dramatically worsened the cardiac condition.

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Section: Discussionmentioning

confidence: 78%

Acute Heart Failure Due to Transient Left Ventricular Dyssynchrony: Case Study

Jourdain

Bauchart

Auffray

et al. 2010

American Journal of Critical Care

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“…After chest pain classification, an 18-lead electrocardiogram (12 conventional plus 4 right precordial and 2 dorsal leads) was performed and ECG was classified as follows: ST segment elevation: when positive J-ST shift greater than 0.1mV occurred in at least 2 contiguous leads in the frontal plane, or greater than 0.2 mV in the horizontal plane; 2) ST segment depression or T wave inversion: when negative J-ST shift equal to or greater than 0.1 mV occurred in at least 2 contiguous leads, or isolated T wave inversion occurred in at least 2 contiguous leads; 3) Left bundle branch block: when, in the presence of sinus rhythm, duration of QRS complexes was equal to or greater than 120 msec, with QS or rS morphology in lead V 1 and QRS intrinsecoid deflection was equal to or greater than 60 msec in leads 1, V 5 and V 6 , associated or not with Q waves in those leads (9) ; 4) Normal or nonspecific: when no changes occurred, or when changes in either QRS duration and morphology, or J-ST shifts, or both were of a lesser degree than the aforementioned ones, even in the presence of old pathologic Q waves.…”

Section: Methodsmentioning

confidence: 99%

Efficacy of a diagnostic strategy for patients with chest pain and no ST-segment elevation in the emergency room

Bassan¹,

Gamarski²,

Pimenta³

et al. 2000

Arq. Bras. Cardiol.

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Purpose -To evaluate the efficacy of a systematic model of care for patients with chest pain and no ST segment elevation in the emergency room. Methods -From 1003 patients submitted to an algorithm diagnostic investigation by probability of acute ischemic syndrome. We analyzed 600 ones with no elevation of ST segment, then enrolled to diagnostic routes of median (route 2) and low probability (route 3) to ischemic syndrome. Results - Efficacy of a Diagnostic Strategy for Patients with Chest Pain and No ST-Segment Elevation in the Emergency Room Original ArticleThe diagnostic management of patients arriving at the emergency room with chest pain is one of the great challenges of medical practice. This is due not only to the fact that several thoracic and nonthoracic diseases can be the cause of the symptom but also because some of these pathologies may have a very high mortality rate, as is the case with aortic dissection, pulmonary embolism and acute myocardial infarction. Therefore, emergency physicians usually are extremely cautious when they see these patients and try to identify and hospitalize those with high-risk diseases. Although aortic dissection and pulmonary embolism are infrequently seen in the emergency room (less than 1% of chest pain patients), acute myocardial infarction and unstable angina are more common (approximately 10% and 20%, respectively) [1][2][3][4] .Acute coronary insufficiency has the electrocardiogram as its diagnostic method of choice. However, several studies have demonstrated that this tool has low sensitivity for the diagnosis of this syndrome (about 50%) 5,6 . The present study tries to establish a rapid and accurate diagnostic strategy for patients seen in the emergency room with chest pain who do not have the typical electrocardiographic feature of acute myocardial infarction ( ST segment elevation ). MethodsPro-Cardiaco Hospital is a primary-and tertiary-care private institution for clinical and cardiologic patients located in the center of the city of Rio de Janeiro, Brazil. It has an active 9-bed emergency room and a cardiologist-staffed ambulance service for house-calls.To improve care of patients with chest pain and to make the diagnostic and therapeutic management uniform between attending physicians and house-staff, a diagnostic strategy was created according to the pretest probability of acute coronary insufficiency 6 . A systematic model was developed

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“…In these leads, STE with a prominent T wave is seen. The STE in these leads ranges from minimal (1-2 mm) to prominent (O5 mm), although STE O5mm in these leads should spark consideration of AMI [22]. Moving from the right to left precordial leads, poor R wave progression or QS complexes are noted, rarely extending beyond leads V4 or V5.…”

Section: Bundle Branch Blockmentioning

confidence: 99%

ST Segment and T Wave Abnormalities Not Caused by Acute Coronary Syndromes

Brady

2006

Emergency Medicine Clinics of North America

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The evaluation of the chest pain patient suspected of acute coronary syndrome (ACS) represents the major indication for electrocardiograph (ECG) performance in the emergency department (ED) and prehospital settings [1]. The ECG demonstrates significant abnormality in a minority of these patients, ranging from minimal nonspecific ST segment/T wave changes to pronounced STE and T wave abnormalities, including the prominent T wave, the inverted T wave, and the nonspecific T wave (Figs. 1 and 2). The ECG syndromes responsible for these various abnormalities include potentially malignant entities, such as ACS and cardiomyopathy, and less concerning patterns, such as benign early repolarization (BER) or ventricular paced rhythms (VPR) [2][3][4].In a study considering all chest pain patients with electrocardiographic ST segment depression (STD), the following clinical syndromes were responsible for the ECG abnormality: ACS, 26%; left ventricular hypertrophy (LVH), 43%; bundle branch block (BBB), 21%; VPR, 5%; left ventricular aneurysm, 3%; and other patterns, 1% [5]. Similarly, STE is a fairly common finding on the ECG of the chest pain patient and frequently does not indicate STE acute myocardial infarction (AMI). One prehospital study of adult chest pain patients revealed that, of patients manifesting STE who met criteria for fibrinolysis, most were not diagnosed with AMI; rather, LVH and left BBB were found more frequently [6]. Furthermore, in two reviews of adult ED chest pain patients with STE on ECG, the ST segment abnormality resulted from AMI in only 15%-31% of these populations; LVH, seen in 28%-30% of these patients, was a frequent cause of this STE. Other findings responsible for this STE included BER, acute

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Electrocardiographic Diagnosis of Evolving Acute Myocardial Infarction in the Presence of Left Bundle-Branch Block

Cited by 563 publications

References 45 publications

Acute Heart Failure Due to Transient Left Ventricular Dyssynchrony: Case Study

Acute Heart Failure Due to Transient Left Ventricular Dyssynchrony: Case Study

Efficacy of a diagnostic strategy for patients with chest pain and no ST-segment elevation in the emergency room

ST Segment and T Wave Abnormalities Not Caused by Acute Coronary Syndromes

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