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Khawaja M, Thakker J, Kherallah R, Ye Y, Smith SW, Birnbaum Y. Diagnosis of Occlusion Myocardial Infarction in Patients with Left Bundle Branch Block and Paced Rhythms. Curr Cardiol Rep 2021; 23:187. [PMID: 34791609 DOI: 10.1007/s11886-021-01613-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW A number of criteria have been developed to aid with the diagnosis of occlusion myocardial infarction (OMI) in patients with left bundle branch block (LBBB) and ventricular paced rhythms (VPR). The current guidelines do not provide clear preference for any specific ECG criteria in LBBB and paced rhythm patients. RECENT FINDINGS This review delineates the difficulties of electrocardiographic diagnosis of OMI in both LBBB and VPR patients. We describe the original Sgarbossa and the newer criteria and their diagnostic performances. We highlight the expected changes of newer pacing modalities and how they may interfere with the electrocardiographic diagnosis of OMI. We recommend utilizing the Cai et al. algorithm, which combines clinical assessment with the Smith Modified Sgarbossa ECG criteria, for both LBBB and right ventricular pacing patients with suspected OMI. There is limited data concerning ECG changes of OMI in patients with the newer pacing modalities, such as biventricular, His-bundle, or left bundle branch pacing.
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Affiliation(s)
- Muzamil Khawaja
- Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Janki Thakker
- Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Riyad Kherallah
- Department of Medicine, Baylor College of Medicine, Houston, USA
| | - Yumei Ye
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, USA
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin Healthcare and the University of Minnesota School of Medicine, 701 S. Park Ave. Minneapolis, Minnesota, MN, 55415, USA.
| | - Yochai Birnbaum
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, MS: BCM620. One Baylor Plaza, Houston, TX, 77030, USA.
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Nikus K, Birnbaum Y, Fiol-Sala M, Rankinen J, de Luna AB. Conduction Disorders in the Setting of Acute STEMI. Curr Cardiol Rev 2021; 17:41-49. [PMID: 32614749 PMCID: PMC8142368 DOI: 10.2174/1573403x16666200702121937] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 02/28/2020] [Accepted: 03/12/2020] [Indexed: 11/22/2022] Open
Abstract
ST-elevation myocardial (STEMI) is frequently associated with conduction disorders. Regional myocardial ischemia or injury may affect the cardiac conduction system at various locations, and neural reflexes or changes in the balance of the autonomous nervous system may be involved. Sinoatrial and atrioventricular blocks are more frequent in inferior than anterior STEMI, while new left anterior fascicular block and right bundle branch block indicate proximal occlusion of the left anterior descending coronary artery. New left bundle branch block is associated with multi-vessel disease. Most conduction disorders associated with STEMI are reversible with reperfusion therapy, but they may still impair prognosis because they indicate a large area at risk, extensive myocardial infarction or severe coronary artery disease. Acute STEMI recognition is possible in patients with a fascicular or right bundle branch block, but future studies need to define the cut-off values for ST depression in the leads V1-V3 in inferolateral MI and for ST elevation in the same leads in anterior STEMI. In the left bundle branch block, concordant ST elevation is a specific sign of acute coronary artery occlusion, but the ECG feature has low sensitivity.
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Affiliation(s)
- Kjell Nikus
- Address correspondence to this author at the Department of Cardiology, Heart Center, Tampere University Hospital, Ensitie 4, 33520 Tampere,
Finland; Tel: +358 50 5575 396; E-mail:
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Nestelberger T, Cullen L, Lindahl B, Reichlin T, Greenslade JH, Giannitsis E, Christ M, Morawiec B, Miro O, Martín-Sánchez FJ, Wussler DN, Koechlin L, Twerenbold R, Parsonage W, Boeddinghaus J, Rubini Gimenez M, Puelacher C, Wildi K, Buerge T, Badertscher P, DuFaydeLavallaz J, Strebel I, Croton L, Bendig G, Osswald S, Pickering JW, Than M, Mueller C. Diagnosis of acute myocardial infarction in the presence of left bundle branch block. Heart 2019; 105:1559-1567. [PMID: 31142594 DOI: 10.1136/heartjnl-2018-314673] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 05/01/2019] [Accepted: 05/08/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Patients with suspected acute myocardial infarction (AMI) in the setting of left bundle branch block (LBBB) present an important diagnostic and therapeutic challenge to the clinician. METHODS We prospectively evaluated the incidence of AMI and diagnostic performance of specific ECG and high-sensitivity cardiac troponin (hs-cTn) criteria in patients presenting with chest discomfort to 26 emergency departments in three international, prospective, diagnostic studies. The final diagnosis of AMI was centrally adjudicated by two independent cardiologists according to the universal definition of myocardial infarction. RESULTS Among 8830 patients, LBBB was present in 247 (2.8%). AMI was the final diagnosis in 30% of patients with LBBB, with similar incidence in those with known LBBB versus those with presumably new LBBB (29% vs 35%, p=0.42). ECG criteria had low sensitivity (1%-12%) but high specificity (95%-100%) for AMI. The diagnostic accuracy as quantified by the receiver operating characteristics (ROC) curve of hs-cTnT and hs-cTnI concentrations at presentation (area under the ROC curve (AUC) 0.91, 95% CI 0.85 to 0.96 and AUC 0.89, 95% CI 0.83 to 0.95), as well as that of their 0/1-hour and 0/2-hour changes, was very high. A diagnostic algorithm combining ECG criteria with hs-cTnT/I concentrations and their absolute changes at 1 hour or 2 hours derived in cohort 1 (45 of 45(100%) patients with AMI correctly identified) showed high efficacy and accuracy when externally validated in cohorts 2 and 3 (28 of 29 patients, 97%). CONCLUSION Most patients presenting with suspected AMI and LBBB will be found to have diagnoses other than AMI. Combining ECG criteria with hs-cTnT/I testing at 0/1 hour or 0/2 hours allows early and accurate diagnosis of AMI in LBBB. TRIAL REGISTRATION NUMBER APACE: NCT00470587; ADAPT: ACTRN12611001069943; TRAPID-AMI: RD001107;Results.
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Affiliation(s)
- Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Louise Cullen
- Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Bertil Lindahl
- Department of Cardiology, University Hospital Uppsala, Uppsala, Sweden
| | - Tobias Reichlin
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Jaimi H Greenslade
- Emergency Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | | | - Michael Christ
- Department of Emergency Medicine, Luzerner Kantonsspital, Luzern, Switzerland
| | - Beata Morawiec
- Department of Cardiology, University Hospital, Zabrze, Poland
| | - Oscar Miro
- Department of Emergency Department, Hospital Clinic, Barcelona, Spain
| | | | - Desiree Nadine Wussler
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - William Parsonage
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Maria Rubini Gimenez
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Tobias Buerge
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Jeanne DuFaydeLavallaz
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Ivo Strebel
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Lukas Croton
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Garnet Bendig
- Roche Forschungs-, Entwicklungs- und Produktionszentrum, Penzberg, Germany
| | - Stefan Osswald
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | | | - Martin Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
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Avsec M, Fister M, Noč M, Radsel P. Alternating bundle-branch block in acute coronary syndrome. COR ET VASA 2019. [DOI: 10.1016/j.crvasa.2017.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Di Marco A, Anguera I, Rodríguez M, Sionis A, Bayes-Genis A, Rodríguez J, Ariza-Solé A, Sánchez-Salado JC, Díaz-Nuila M, Masotti M, Villuendas R, Dallaglio P, Gómez-Hospital JA, Cequier Á. Evaluación de los algoritmos de Smith para el diagnóstico de infarto agudo de miocardio en presencia de bloqueo de rama izquierda del haz de His. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Di Marco A, Anguera I, Rodríguez M, Sionis A, Bayes-Genis A, Rodríguez J, Ariza-Solé A, Sánchez-Salado JC, Díaz-Nuila M, Masotti M, Villuendas R, Dallaglio P, Gómez-Hospital JA, Cequier Á. Assessment of Smith Algorithms for the Diagnosis of Acute Myocardial Infarction in the Presence of Left Bundle Branch Block. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2017; 70:559-566. [PMID: 28027906 DOI: 10.1016/j.rec.2016.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/02/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION AND OBJECTIVES Recently, a new electrocardiography algorithm has shown promising results for the the diagnosis of acute myocardial infarction in the presence of left bundle branch block (LBBB). We aimed to assess these new electrocardiography rules in a cohort of patients referred for primary percutaneous coronary intervention (pPCI). METHODS Retrospective observational cohort study that included all patients with suspected myocardial infarction and LBBB on the presenting electrocardiogram, referred for pPCI to 4 tertiary hospitals in Barcelona, Spain. RESULTS A total of 145 patients were included. Fifty four (37%) had an ST-segment elevation myocardial infarction (STEMI) equivalent. Among patients with STEMI, 25 (46%) presented in Killip class III or IV, and in-hospital mortality was 15%. Smith I and II rules performed better than Sgarbossa algorithms and showed good specificity (90% and 97%, respectively) but their sensitivity was 67% and 54%, respectively. In a strategy guided by Smith I or Smith II rules, 18 (33%) or 25 (46%) patients with STEMI would have not received a pPCI, respectively. Moreover, the severity and prognosis of STEMI patients was similar regardless of the positivity of Smith rules. Cardiac biomarkers were positive in 54% of non-STEMI patients, limiting their usefulness for initial diagnostic screening. CONCLUSIONS Diagnosis of STEMI in the presence of LBBB remains a challenge. Smith rules can be useful but are limited by suboptimal sensitivity. The search for new electrocardiography algorithms should be encouraged to avoid unnecessary aggressive treatments in the majority of patients, while providing timely reperfusion to a high-risk subgroup of patients.
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Affiliation(s)
- Andrea Di Marco
- Área del Corazón, Servicio de Cardiología, Hospital Universitario de Bellvitge, Barcelona, Spain.
| | - Ignasi Anguera
- Área del Corazón, Servicio de Cardiología, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Marcos Rodríguez
- Área del Corazón, Servicio de Cardiología, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | - Antoni Bayes-Genis
- Servicio de Cardiología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Jany Rodríguez
- Servicio de Cardiología, Hospital Clínic, Barcelona, Spain
| | - Albert Ariza-Solé
- Área del Corazón, Servicio de Cardiología, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | | | - Mónica Masotti
- Servicio de Cardiología, Hospital Clínic, Barcelona, Spain
| | - Roger Villuendas
- Servicio de Cardiología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Paolo Dallaglio
- Área del Corazón, Servicio de Cardiología, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | - Ángel Cequier
- Área del Corazón, Servicio de Cardiología, Hospital Universitario de Bellvitge, Barcelona, Spain
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von Jeinsen B, Tzikas S, Pioro G, Palapies L, Zeller T, Bickel C, Lackner KJ, Baldus S, Blankenberg S, Muenzel T, Zeiher AM, Keller T. Troponin I Assay for Identification of a Significant Coronary Stenosis in Patients with Suspected Acute Myocardial Infarction and Wide QRS Complex. PLoS One 2016; 11:e0154724. [PMID: 27148734 PMCID: PMC4858235 DOI: 10.1371/journal.pone.0154724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 04/18/2016] [Indexed: 12/02/2022] Open
Abstract
Background Common ECG criteria such as ST-segment changes are of limited value in patients with suspected acute myocardial infarction (AMI) and bundle branch block or wide QRS complex. A large proportion of these patients do not suffer from an AMI, whereas those with ST-elevation myocardial infarction (STEMI) equivalent AMI benefit from an aggressive treatment. Aim of the present study was to evaluate the diagnostic information of cardiac troponin I (cTnI) in hemodynamically stable patients with wide QRS complex and suspected AMI. Methods In 417 out of 1818 patients presenting consecutively between 01/2007 and 12/2008 in a prospective multicenter observational study with suspected AMI a prolonged QRS duration was observed. Of these, n = 117 showed significant obstructive coronary artery disease (CAD) used as diagnostic outcome variable. cTnI was determined at admission. Results Patients with significant CAD had higher cTnI levels compared to individuals without (median 250ng/L vs. 11ng/L; p<0.01). To identify patients needing a coronary intervention, cTnI yielded an area under the receiver operator characteristics curve of 0.849. Optimized cut-offs with respect to a sensitivity driven rule-out and specificity driven rule-in strategy were established (40ng/L/96ng/L). Application of the specificity optimized cut-off value led to a positive predictive value of 71% compared to 59% if using the 99th percentile cut-off. The sensitivity optimized cut-off value was associated with a negative predictive value of 93% compared to 89% provided by application of the 99th percentile threshold. Conclusion cTnI determined in hemodynamically stable patients with suspected AMI and wide QRS complex using optimized diagnostic thresholds improves rule-in and rule-out with respect to presence of a significant obstructive CAD.
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Affiliation(s)
- Beatrice von Jeinsen
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- * E-mail: (TK); (BJ)
| | - Stergios Tzikas
- 3rd Department of Cardiology, Aristotle University of Thessaloniki, Ippokrateio Hospital, Thessaloniki, Greece
- Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Gerhard Pioro
- Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Lars Palapies
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Christoph Bickel
- Department of Internal Medicine, Federal Armed Forces Hospital, Koblenz, Germany
| | - Karl J. Lackner
- Department of Laboratory Medicine, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Stephan Baldus
- Department of Internal Medicine III, University of Cologne, Köln, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Thomas Muenzel
- Department of Internal Medicine II, University Medical Center, Johannes Gutenberg University, Mainz, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Andreas M. Zeiher
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Till Keller
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
- * E-mail: (TK); (BJ)
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Deshpande A, Birnbaum Y. ST-segment elevation: Distinguishing ST elevation myocardial infarction from ST elevation secondary to nonischemic etiologies. World J Cardiol 2014; 6:1067-1079. [PMID: 25349651 PMCID: PMC4209433 DOI: 10.4330/wjc.v6.i10.1067] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 05/20/2014] [Accepted: 07/29/2014] [Indexed: 02/07/2023] Open
Abstract
The benefits of early perfusion in ST elevation myocardial infarctions (STEMI) are established; however, early perfusion of non-ST elevation myocardial infarctions has not been shown to be beneficial. In addition, ST elevation (STE) caused by conditions other than acute ischemia is common. Non-ischemic STE may be confused as STEMI, but can also mask STEMI on electrocardiogram (ECG). As a result, activating the primary percutaneous coronary intervention (pPCI) protocol often depends on determining which ST elevation patterns reflect transmural infarction due to acute coronary artery thrombosis. Coordination of interpreting the ECG in its clinical context and appropriately activating the pPCI protocol has proved a difficult task in borderline cases. But its importance cannot be ignored, as reflected in the 2013 American College of Cardiology Foundation/American Heart Association guidelines concerning the treatment of ST elevation myocardial infarction. Multiples strategies have been tested and studied, and are currently being further perfected. No matter the strategy, at the heart of delivering the best care lies rapid and accurate interpretation of the ECG. Here, we present the different patterns of non-ischemic STE and methods of distinguishing between them. In writing this paper, we hope for quicker and better stratification of patients with STE on ECG, which will lead to be better outcomes.
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Ayer A, Terkelsen CJ. Difficult ECGs in STEMI: lessons learned from serial sampling of pre- and in-hospital ECGs. J Electrocardiol 2014; 47:448-58. [PMID: 24792903 DOI: 10.1016/j.jelectrocard.2014.03.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Indexed: 12/13/2022]
Abstract
Prehospital interpretation of electrocardiograms (ECGs) is crucial to ensure early diagnosis and optimal treatment of patients with ST elevation myocardial infarction (STEMI). Recognition of ST-segment elevations (STE) by qualified personnel in the prehospital phase has successfully reduced the delay from the first medical contact to reperfusion. A few other ECG patterns without true STE, referred to as "STEMI equivalents", bear the same prognostic significance, reflect imminent or ongoing transmural ischemia, but are less easily identified. Hyperacute T waves, de Winter ST-T complex, Wellens' syndrome, and posterior STEMI, as well as myocardial infarction in the presence of left bundle branch block, paced rhythm or left ventricular hypertrophy, among others are diagnostic challenges. This article reviews some critical examples of ischemic ECG patterns that may be ephemeral, misinterpreted by medical staff or not identified by automated ECG algorithms, and it emphasizes the importance of serial ECG acquisition.
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Affiliation(s)
- Antoine Ayer
- Department of cardiology, Aarhus University Hospital, Skejby, DK-8200 Aarhus N, Denmark.
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Diffuse ST depression with ST elevation in aVR: Is this pattern specific for global ischemia due to left main coronary artery disease? J Electrocardiol 2013; 46:240-8. [DOI: 10.1016/j.jelectrocard.2012.12.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Indexed: 11/17/2022]
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Brown AJ, Hoole SP, McCormick LM, Malone-Lee M, Cacciottolo PJ, Schofield PM, West NEJ. Left bundle branch block with acute thrombotic occlusion is associated with increased myocardial jeopardy score and poor clinical outcomes in primary percutaneous coronary intervention activations. Heart 2013; 99:774-8. [DOI: 10.1136/heartjnl-2012-303194] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Madias JE. Left bundle branch block and suspected acute myocardial infarction. J Electrocardiol 2013; 46:11-2. [DOI: 10.1016/j.jelectrocard.2012.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Indexed: 11/16/2022]
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