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Sörensen NA, Fakhri Y, Goßling A, Neumann JT, Haller PM, Toprak B, Senftinger J, Lehmacher J, Scharlemann L, Schock A, Twerenbold R, Westermann D, Bille Andersson H, Jensen LO, Holmvang L, Clemmensen P. Impact of Quantitative ST-T Analysis in Patients With Suspected Myocardial Infarction Presenting With Right Bundle Branch Block. Am J Med 2024; 137:770-775.e1. [PMID: 38670517 DOI: 10.1016/j.amjmed.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/16/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND While left bundle branch block (LBBB) is a well-known risk feature in patients with acute myocardial infarction, and a rapid invasive management is recommended, data supporting this strategy for patients with right bundle branch block (RBBB) is less robust. METHODS In total, 2139 patients with suspected ST-elevation myocardial infarction (STEMI) were triaged to acute coronary angiography based on a prehospital 12-lead electrocardiogram (ECG). Sensitivity and specificity for STEMI-ECG criteria were compared in RBBB and non-BBB patients. Adjusted hazard ratios for 1-year overall mortality were computed. RESULTS STEMI was adjudicated in 1832/2139 (85.6%) of all patients and in 102/117 (87.2%) of RBBB patients. ST-segment deviation followed typical ST-T patterns in most RBBB patients. Of 17 RBBB patients without significant ST changes, STEMI was adjudicated in 14 (82%). Diagnostic accuracy of STEMI criteria was comparable in RBBB and non-RBBB patients for inferior (sensitivity: 51.1% vs 59.1%, P = .14; specificity: 66.7% vs 52.1%, P = .33) and anterior STEMI (sensitivity: 35.2% vs 36.6%, P = .80; specificity: 58.3% vs 49.5%, P = .55). Diagnostic performance was lower for lateral STEMI in RBBB patients (sensitivity: 14.8% vs 4.4%, P = .001; specificity: 75.0% vs 98.4%, P < .001). Patients with RBBB had higher 1-year mortality compared with non-BBB patients (hazard ratio 2.3%; 95% confidence interval, 1.25-4.21. CONCLUSION ECG criteria used for detection of STEMI showed comparable diagnostic accuracy in RBBB and non-BBB patients. However, STEMI was frequently present in RBBB patients not fulfilling diagnostic ECG criteria. RBBB patients showed poorer outcome after 1 year. Consequently, the presence of RBBB in suspected STEMI cases signifies a high-risk feature, aligning with established guidelines.
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Affiliation(s)
- Nils A Sörensen
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
| | - Yama Fakhri
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark; Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark
| | - Alina Goßling
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany
| | - Johannes T Neumann
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Clayton, Vic, Australia
| | - Paul M Haller
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Betül Toprak
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Juliana Senftinger
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany
| | - Jonas Lehmacher
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany
| | - Lea Scharlemann
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany
| | - Alina Schock
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany
| | - Raphael Twerenbold
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; University Center of Cardiovascular Science (UCCS), University Heart and Vascular Center Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Department of Cardiology, University Heart Center, Freiburg/Bad Krotzingen, Germany
| | | | | | - Lene Holmvang
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark
| | - Peter Clemmensen
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany; Department of Medicine, Nykoebing Falster Hospital, Kolding, Denmark
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Inferior ST-Segment Elevation Can Predict In-Hospital Mortality in Patients with Anterior Myocardial Infarction Complicated by Ventricular Septal Rupture. DISEASE MARKERS 2022; 2022:7067420. [PMID: 35872699 PMCID: PMC9307369 DOI: 10.1155/2022/7067420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/30/2022] [Accepted: 07/01/2022] [Indexed: 11/25/2022]
Abstract
Background Electrocardiogram (ECG) findings in patients with anterior wall myocardial infarction (MI) complicated by ventricular septal rupture (VSR) have rarely been studied. Methods We conducted a single-center retrospective study among patients with anterior MI complicated by VSR over the past ten years. The presence of ST-segment elevation (STE) in inferior leads and new onset of complete right bundle branch block (RBBB) on ECG were studied for the prediction of in-hospital mortality. Results Among the 85 patients enrolled, 45 (52.9%) were male, with a median age of 70 years. Sixty-five patients (76.5%) died in the hospital, and the remaining 20 patients (23.5%) had improved conditions and were discharged. Inferior STE was present in 35 patients (41.2%), including 32 patients in the death group and 3 patients in the survival group (P = 0.005). New-onset RBBB was present in 25 patients (29.4%), with 22 patients in the death group and 3 patients in the survival group (P = 0.103). Multivariate logistic regression showed that inferior STE was an independent predictor of in-hospital death in patients with anterior MI and VSR (OR: 14.488; 95% CI: 1.708-122.887; P = 0.014). Conclusions In patients with anterior MI complicated by VSR, inferior STE was associated with a higher risk of in-hospital mortality.
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Basit H, Kahn A, Zaidi S, Chadow H, Khan A. A Case of ST-Elevation Myocardial Infarction With Right Bundle Branch Block, an Ominous Sign of Critical Coronary Occlusion. Cureus 2022; 14:e21216. [PMID: 35174024 PMCID: PMC8840869 DOI: 10.7759/cureus.21216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2021] [Indexed: 11/12/2022] Open
Abstract
Coronary artery disease is one of the leading causes of death worldwide, and ST-elevation myocardial infarction (STEMI) is one of its most serious manifestations. While STEMI itself is an ominous sign, there are other sinister electrocardiogram (EKG) patterns that are associated with increased morbidity and mortality, one of which is STEMI with right bundle branch block (RBBB). Blood supply to the right bundle comes from the left coronary circulation. Intuitively, RBBB in the setting of anterior wall myocardial infarction would indicate more extensive myocardial involvement and thus portend a worse prognosis. This case presents the significance of the association of new RBBB with critical lesions of the left anterior descending artery (LAD), therefore a low threshold for emergent coronary angiography and percutaneous coronary intervention (PCI). A 63-year-old man with a known history of non-insulin-dependent diabetes mellitus (NIDDM), hypertension, and hypertriglyceridemia non-compliant with medications presented to the emergency department (ED) after a visit with his primary care physician, with a chief complaint of exertional substernal chest pain for a one-week duration. His EKG on arrival showed significant ST-segment elevation with an atypical EKG pattern showing RBBB in V1-V2 with ST depression in reciprocal leads. Cardiac biomarkers showed an initial troponin I value of 0.441 ng/mL. Due to his persistent, worsening chest pain and associated nausea with episodes of vomiting, he was taken for an emergent cardiac catheterization that revealed a 100% lesion in his proximal LAD. The procedure was complicated by the development of cardiogenic shock requiring intra-aortic balloon pumps and vasopressors. A successful primary PCI was performed with drug-eluting stent (DES) to the 100% lesion in the proximal LAD and DES to the 80% lesions in the mid LAD, with 0% residual stenosis after the intervention. There was thrombolysis in myocardial infarction (TIMI) 0 flow pre-procedure and TIMI 3 flow post-intervention. Left ventriculography revealed anterolateral akinesis, apical akinesis, and diaphragmatic hypokinesis with an estimated ejection fraction (EF) of 20%. Transthoracic echocardiogram was repeated prior to discharge. Left ventricular (LV) systolic function was normal by visual assessment, and EF was noted to be ~55%. The patient continued on dual antiplatelet therapy and the rest of goal-directed medical therapy for coronary artery disease post-procedure. New-onset RBBB in the patient with typical STEMI in the context of ischemic symptoms should raise suspicion of critical proximal LAD coronary occlusion. It is increasingly being recognized as one of the significant EKG patterns for occlusive myocardial infarction associated with the worst outcome and mortality, highlighting the need to pay critical attention to these patients. Given the poor prognosis of these patients in the setting of acute myocardial infarction (AMI), it is essential to minimize the delay in initiating reperfusion therapy as they can potentially benefit from emergent intervention.
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Zhu T, Chen M, Hu W, Wang B, Jiang H. Clinical characteristics and the severity of coronary atherosclerosis of different subtypes of bundle-branch block. Ann Noninvasive Electrocardiol 2021; 27:e12883. [PMID: 34258804 PMCID: PMC8739622 DOI: 10.1111/anec.12883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/29/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Right bundle-branch block (RBBB) and left bundle-branch block (LBBB) play a role in the pathogenesis and progression of coronary artery disease (CAD). However, the clinical features and the severity of coronary artery disease associated with different subtypes of bundle-branch block, according to time of new appearance, is not well characterized in patients with no known CAD. METHODS We retrospectively analyzed data pertaining to consecutive patients with RBBB or LBBB who underwent coronary angiography. The severity of coronary lesions was evaluated using the SYNTAX score. The differential effect of new-onset RBBB, old RBBB, new-onset LBBB, and old LBBB on the severity of CAD and its association with clinical characteristics was quantified. Multivariate logistic regression analysis was performed to evaluate the effect of RBBB and LBBB on the degree of coronary atherosclerosis in patients without known CAD. RESULTS Out of the 243 patients, 72 patients had old LBBB, 37 had new-onset LBBB, 93 patients had old RBBB, and 41 patients had new-onset RBBB. On univariate analysis, age, systolic blood pressure, diastolic blood pressure, creatinine, serum glucose, and glycosylated hemoglobin level were associated with high SYNTAX score (p < .05 for all). Patients in the new-onset RBBB, old RBBB, new-onset LBBB, and old LBBB groups showed significant differences in baseline characteristics and coronary atherosclerosis (p < .05 for all). However, there were no significant between-group differences with respect to the degree of coronary atherosclerosis as assessed by SYNTAX score. CONCLUSIONS New-onset RBBB, old RBBB, new-onset LBBB, and old LBBB were not associated with the severity of coronary lesions as assessed by SYNTAX score in patients without known CAD.
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Affiliation(s)
- Tongjian Zhu
- Department of Cardiology, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Renmin Hospital of Wuhan University, Wuhan University, Wuhan, Hubei, China
| | - Mingxian Chen
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wei Hu
- Department of Cardiology, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Renmin Hospital of Wuhan University, Wuhan University, Wuhan, Hubei, China
| | - Benfang Wang
- Department of Cardiology, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Hong Jiang
- Department of Cardiology, Cardiovascular Research Institute, Hubei Key Laboratory of Cardiology, Renmin Hospital of Wuhan University, Wuhan University, Wuhan, Hubei, China
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Birnbaum Y, Nikus K, Atar D, Jneid H. Is RBBB the new LBBB? Are we going to repeat the same mistakes? J Electrocardiol 2021; 65:34-36. [PMID: 33477070 DOI: 10.1016/j.jelectrocard.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Yochai Birnbaum
- The Section of Cardiology, The Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America.
| | - Kjell Nikus
- Heart Center, Tampere University, Hospital and Faculty of Medicine, Finland; Faculty of Medicine, Tampere University, Finland
| | - Dan Atar
- Dept. of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway; Institute of Clinical Sciences, Norway
| | - Hani Jneid
- The Section of Cardiology, The Department of Medicine, Baylor College of Medicine, Houston, TX, United States of America
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