Diagnostische Wertigkeit des Linksschenkelblocks bei Patienten mit akutem Myokardinfarkt

Impact of Newly Diagnosed Left Bundle Branch Block on Long-Term Outcomes in Patients with STEMI

Background/Objectives: This study assessed the long-term prognostic implications of newly developed left bundle branch block (LBBB) in patients with ST-elevation myocardial infarction (STEMI) and a single coronary lesion, following primary percutaneous coronary intervention (PCI). Methods: Among 3526 patients admitted with acute myocardial infarction between January 2011 and December 2013, 42 were identified with STEMI, a single coronary lesion, and newly diagnosed LBBB. A control group of 42 randomly selected STEMI patients without LBBB was also included. All participants were prospectively evaluated with a median follow-up duration of 9.4 years. Demographic, clinical, and laboratory data were analyzed to assess the impact of LBBB on long-term outcomes. Results: The baseline characteristics were similar between the groups. The STEMI with new LBBB group had significantly higher rates of new myocardial infarction, revascularization, and mortality, highlighting the severe prognostic implications and elevated risk for adverse outcomes compared to STEMI without LBBB. The multivariate Cox regression analysis demonstrated that the presence of LBBB (HR: 2.15, 95% CI: 1.28-3.62, p = 0.003), lower LVEF (HR: 1.45, 95% CI: 1.22-1.72, p < 0.001), and longer pain-to-admission time (HR: 1.32, 95% CI: 1.09-1.61, p = 0.008) were significant independent predictors of adverse outcomes. Conclusions: Newly acquired LBBB in STEMI patients is associated with poorer long-term outcomes. Early identification and management of factors such as reduced LVEF and timely hospital admission, specifically in patients with new-onset LBBB, can improve prognosis.

Risk Prediction in Cardiogenic Shock: Current State of Knowledge, Challenges and Opportunities

Cardiogenic shock (CS) is a condition associated with high mortality rates in which prognostication is uncertain for a variety of reasons, including its myriad causes, its rapidly evolving clinical course and the plethora of established and emerging therapies for the condition. A number of validated risk scores are available for CS prognostication; however, many of these are tedious to use, are designed for application in a variety of populations and fail to incorporate contemporary hemodynamic parameters and contemporary mechanical circulatory support interventions that can affect outcomes. It is important to separate patients with CS who may recover with conservative pharmacological therapies from those in who may require advanced therapies to survive; it is equally important to identify quickly those who will succumb despite any therapy. An ideal risk-prediction model would balance incorporation of key hemodynamic parameters while still allowing dynamic use in multiple scenarios, from aiding with early decision making to device weaning. Herein, we discuss currently available CS risk scores, perform a detailed analysis of the variables in each of these scores that are most predictive of CS outcomes and explore a framework for the development of novel risk scores that consider emerging therapies and paradigms for this challenging clinical entity.

Left bundle-branch block in patients with acute myocardial infarction: Presentation, treatment, and trends in outcome from 1997 to 2016 in routine clinical practice

BACKGROUND

Whether patients with acute myocardial infarction presenting with new or presumed new left bundle-branch block (LBBB) should be treated in the same way as those presenting with ST-elevation (STE) is still a matter of debate.

METHODS

Data from 28,358 patients enrolled in AMIS Plus from 1997 to 2016 were analyzed to evaluate differences in treatment and outcome of patients presenting with LBBB (n=2295) or STE (n=26,090) on their initial electrocardiogram using descriptive statistics and multivariate logistic regression.

RESULTS

LBBB patients were older (75.0 vs 64.3 years, P<.001) with a greater burden of risk factors and comorbidities. They were admitted 80 minutes later and more frequently in Killip III/IV (20% vs 7%, P<.001). Even after adjustment for age and gender, LBBB patients were less likely to receive aspirin (odds ratio [OR] 0.40, 95% CI 0.34-0.47), P2Y12 inhibitors (OR 0.50, 95% CI 0.45-0.54), β-blockers (OR 0.81, 95% CI 0.76-0.89), and statins (OR 0.70, 95% CI 0.63-0.76) or undergo percutaneous coronary interventions (OR 0.38, 95% CI 0.35-0.42). Crude in-hospital mortality of patients with LBBB was 16.2% versus 6.5% for patients with STE, but adjusted OR was 1.07 (95% CI 0.93-1.24). Mortality of LBBB patients decreased from 22.6% in 1997-2001 to 11.9% in 2012-2016.

CONCLUSIONS

Acute myocardial infarction patients with new or presumed new LBBB presence are at high risk of morbidity and mortality. They were treated less aggressively, and although mortality has halved during the last 20 years, there may be room for further improvement. Additional studies are needed to better identify those patients with LBBB who may maximally benefit from an early invasive treatment strategy.