Left bundle branch block as equivalent of ST-segment elevation myocardial infarction: when yes, when not?

Rationale: Left bundle branch block is a diagnostic utility for ST-segment elevation myocardial infarction equivalent. Consequently, administration of thrombolytic is a pivotal step. Emergent Sgarbosa criteria and their modification are considered helpful guide keys. Wavy triple an electrocardiographic sign (Yasser Sign) is a novel diagnostic sign in hypocalcemia. Interestingly, the presentation of COVID-19 pneumonia with an intertwining left bundle branch block, renal impairment, and hypocalcemia has a risk impact on both morbidity and mortality of COVID-19 patients. Patient concerns: An elderly carpenter male COVID-19 patient was admitted to intensive care unit with COVID-19 pneumonia with interlacing left bundle branch block, renal impairment, and Wavy triple sign (Yasser’s sign). Diagnosis: Left bundle branch block and Wavy triple sign (Yasser’s sign) intertwining COVID-19 pneumonia with renal impairment. Interventions: Arterial blood gases, chest CT scan, electrocardiography, oxygenation, and echocardiography. Outcomes: Gradual dramatic clinical, electrocardiographic, and radiological improvement had happened. Lessons: The triage of the left bundle branch block with the COVID-19 patient is highly significant for both diagnosis of acute myocardial infarction and giving thrombolytic. The combination of left bundle branch block, renal impairment, and hypocalcemia COVID-19 pneumonia signifies the risk in the current case study.

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Right bundle branch block masquerading as acute ST-segment elevation myocardial infarction

The Southwest Respiratory and Critical Care Chronicles ◽

10.12746/swrccc.v8i33.649 ◽

2020 ◽

Vol 8 (33) ◽

pp. 72-73

Author(s):

Wasawat Vutthikraivit ◽

Sakolwan Suchartlikitwong

Keyword(s):

Myocardial Infarction ◽

Right Bundle Branch Block ◽

Bundle Branch Block ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment

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Clinical and Angiographic Prole of Patients with Left Bundle Branch Block

Ibrahim Cardiac Medical Journal ◽

10.3329/icmj.v6i1-2.53756 ◽

2018 ◽

Vol 6 (1-2) ◽

pp. 14-19

Author(s):

Sahela Nasrin ◽

F Aaysha Cader ◽

M Maksumul Haq

Keyword(s):

Myocardial Infarction ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Systolic Dysfunction ◽

Bundle Branch Block ◽

St Segment Elevation ◽

Vessel Disease ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

Artery Disease

Background & objective: Left bundle branch block (LBBB), resulting in an alteration of the normal sequence of activation in the left ventricle, commonly occurs in patients with underlying heart disease particularly coronary artery disease (CAD), but it may also be associated with progressive conducting system disease in an otherwise structurally normal heart. The aim of this study was to evaluate the clinical and angiographic profile of patients presenting with LBBB. Materials & Methods: This study was a cross-sectional observational study. A total of 542 patients of LBBB (as evident by ECG) who underwent coronary angiography from 1st September 2005 to 31st August 2016 were identified from the records of Cath Lab database of Ibrahim Cardiac Hospital & Research Institute and were selected for the study. LBBB was defined as a QRS complex duration ≥120 ms with a broad notched or slurred R wave in leads I, aVL, V5 and V6. Results: Majority (95.8%) of the patients was over 40 years of age with mean age being 59.7 ± 10.7 years (range: 25-95 years). Nearly 60% of the patients were male, 62.2% diabetic and 69.7% hypertensive. Over one-third (37.1%) of patients had moderate left ventricular (LV) systolic dysfunction (ejection fraction 30-44%) and 7% had severe LV systolic dysfunction. Over half (51.9%) had normal body mass index. Unstable angina (45.8%) was the most common indication for angiography. Other indications included non-ST segment elevation myocardial infarction (17.2%), ST segment elevation myocardial infarction (11.3%), stable coronary artery disease (SCAD) (9.8%), prior myocardial infarction (13.3%) and atypical chest pain (2.6%). Nearly 60% of the patients had obstructive coronary artery disease and the rest (40.6%) had normal epicardial coronaries on angiography. Among those with obstructive CAD, 4.1% had left main disease, 20.5% had triple vessel disease (TVD), 14.4% double vessel disease (DVD) and 9.5% single vessel disease (SVD). Conclusion: There is an optimum prevalence of CAD among LBBB patients, with TVD being predominant. LBBB cases with normal coronaries are no less. The latter cases suggest an alternative cause for LBBB. Thus, the usual diagnosis of CAD in patients with presumably new onset LBBB may be over-estimated in clinical practice. Ibrahim Card Med J 2016; 6 (1&2): 14-19

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Differences in presentation and clinical outcomes between left or right bundle branch block and ST segment elevation in patients with acute myocardial infarction

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872620905101 ◽

2020 ◽

Vol 9 (8) ◽

pp. 848-856

Author(s):

Matthias R Meyer ◽

Dragana Radovanovic ◽

Giovanni Pedrazzini ◽

Hans Rickli ◽

Marco Roffi ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Hospital Mortality ◽

Right Bundle Branch Block ◽

Left Bundle Branch Block ◽

Bundle Branch Block ◽

St Segment Elevation ◽

Cerebrovascular Events ◽

St Segment ◽

Ischaemic Attack

Background: In patients with acute myocardial infarction, the presence of a left bundle branch block or right bundle branch block may be associated with worse prognosis compared to isolated ST segment elevation. However, specificities in clinical presentation and outcomes of acute myocardial infarction patients with left bundle branch block or right bundle branch block are poorly characterized. Methods: We analysed acute myocardial infarction patients with left bundle branch block ( n=880), right bundle branch block ( n=732) or ST segment elevation without bundle branch block ( n=15,852) included in the Acute Myocardial Infarction in Switzerland-Plus registry between 2008–2019. Results: Acute myocardial infarction patients with bundle branch block were older and had more pre-existing cardiovascular conditions compared to ST segment elevation. Pulmonary oedema and cardiogenic shock were most frequent in patients with left bundle branch block (18.8% vs 12.0% for right bundle branch block and 7.9% for ST segment elevation, p<0.001). Acute myocardial infarction patients with bundle branch block had more three-vessel (40.6% vs 25.3%, p<0.001 vs ST segment elevation) and left main disease (5.6% vs 2.0%, p<0.001 vs ST segment elevation). Major adverse cardiac and cerebrovascular events, a composite of reinfarction, stroke/transient ischaemic attack, and death during hospitalization, were highest in acute myocardial infarction patients with left bundle branch block (13.9% vs 9.9% for right bundle branch block and 6.7% for ST segment elevation, p<0.05), which was driven by hospital mortality. After multivariate adjustment, however, mortality was similar in patients with left bundle branch block and lower in patients with right bundle branch block, respectively, when compared to ST segment elevation. Mortality was only increased when a right bundle branch block with concomitant STE was present (odds ratio 1.77, 95% confidence interval 1.19–2.64, p<0.01 vs ST segment elevation). Conclusions: Compared to ST segment elevation, an isolated bundle branch block reflects high-risk clinical characteristics but does not independently determine increased hospital mortality in acute myocardial infarction.

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Clinical Presentations and Outcomes in Patients Presenting With Acute Cardiac Events and Right Bundle Branch Block

Angiology ◽

10.1177/0003319719892159 ◽

2019 ◽

Vol 71 (3) ◽

pp. 256-262 ◽

Cited By ~ 1

Author(s):

Fahad Alkindi ◽

Ayman El-Menyar ◽

Ihsan Rafie ◽

Abdulrahman Arabi ◽

Jassim Al Suwaidi ◽

...

Keyword(s):

Myocardial Infarction ◽

Right Bundle Branch Block ◽

Independent Predictor ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Cardiac Events ◽

Bundle Branch Block ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment

We conducted a retrospective analysis of 50 974 patients admitted with acute cardiac events with and without right bundle branch block (RBBB) over 23 years. Compared to non-RBBB, patients with RBBB (n = 386; 0.8%) were 3 years older ( P = .001), more likely to present with breathlessness rather than chest pain ( P = .001), and had more diabetes mellitus ( P = .001). Patients with RBBB had significantly higher cardiac enzymes ( P = .001); however, there were no significant differences in the presentation with ST-segment elevation myocardial infarction (24.6% vs 22.2%), non-ST-segment elevation myocardial infarction (23.7% vs 22.4%), and unstable angina (51.7% vs 55.4%). Patients with RBBB were more likely to have congestive heart failure (CHF; 9.6% vs 3.2%, P = .001), cardiogenic shock (10.6% vs 1.7%, P = .001), and ventricular tachyarrhythmias (7.3% vs 2.2%, P = .001). Left ventricular ejection fraction and hospital length of stay were comparable between the groups. All-cause mortality was 5 times greater in patients with RBBB (21% vs 4.2%, P = .001). Right bundle branch block was independent predictor of mortality (adjusted odd ratio 5.14; 95% confidence interval: 3.90-6.70). Subanalysis comparing normal QRS, RBBB, and left BBB showed that RBBB was associated with the worst outcomes except for CHF. Although RBBB presents in only about 1% of patients with cardiac disease, it was found to be an independent predictor of hospital mortality.

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Right bundle branch block in patients with suspected myocardial infarction

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872618809700 ◽

2018 ◽

Vol 8 (2) ◽

pp. 161-166 ◽

Cited By ~ 8

Author(s):

Johannes Tobias Neumann ◽

Nils Arne Sörensen ◽

Nicole Rübsamen ◽

Francisco Ojeda ◽

Sarina Schäfer ◽

...

Keyword(s):

Myocardial Infarction ◽

Right Bundle Branch Block ◽

European Society ◽

Final Diagnosis ◽

Bundle Branch Block ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

One Year ◽

European Society Of Cardiology

Aims: The new European Society of Cardiology guideline for ST-segment elevation myocardial infarction recommends that left and right bundle branch block should be considered equal for recommending urgent angiography in patients with suspected myocardial infarction. We aimed to evaluate this novel recommendation in two prospective studies of patients with suspected myocardial infarction. Methods and results: We included 4067 patients presenting to the emergency department with suspected myocardial infarction. All patients had an ECG recorded immediately upon admission. Patients were classified as having right bundle branch block (RBBB), left bundle branch block (LBBB), bifascicular block (BFB) or no bundle branch block. All patients were followed for up to two years to assess mortality. In the overall population 125 (3.1%) patients had RBBB, 281 (6.9%) LBBB and 60 (1.5%) BFB. The final diagnosis of myocardial infarction was adjudicated in 20.8% (RBBB), 28.5% (LBBB), 23.3% (BFB) and 21.6% (no complete block) of patients. The mortality rate after one year was 10.7% (RBBB), 7% (LBBB), 17.5% (BFB) and 3.2% (no complete block). The adjusted hazard ratios were 1.29 (95% confidence interval (CI) 0.71–2.34; P=0.40) for RBBB, 1.71 (95% CI 1.17–2.50; P=0.006) for LBBB and 2.27 (95% CI 1.28–4.05; P=0.005) for BFB. Conclusion: Our results support the new European Society of Cardiology ST-segment elevation myocardial infarction guideline describing RBBB as a high risk for mortality in patients with suspected myocardial infarction. However, the data challenge the concept of RBBB as a trigger of acute angiography because the likelihood of myocardial infarction in a chest pain unit setting is equally frequent in patients without bundle branch block.

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Electrocardiographic signs of acute myocardial infarction in left bundle branch block

Medicinski pregled ◽

10.2298/mpns1312503i ◽

2013 ◽

Vol 66 (11-12) ◽

pp. 503-506

Author(s):

Igor Ivanov ◽

Sonja Bugarski ◽

Jadranka Dejanovic ◽

Anastazija Stojsic-Milosavljevic ◽

Jasna Radisic-Bosic ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Chest Pain ◽

Sensitivity And Specificity ◽

Left Bundle Branch Block ◽

Bundle Branch Block ◽

Duration Of Symptoms ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment

Introduction. Acute myocardial infarction is characterized by typical chest pain, electrocardiographic changes in terms of lesion and/or myocardial ischemia and increased cardiac enzymes. It is often difficult to make diagnosis in the presence of non-specific chest pain, the short duration of symptoms and electrocardiographic signs of a complete left bundle branch block. Literature Review. Many authors have tried to set the electrocardiographic criteria that can increase the possibility of correct diagnosis of acute myocardial infarction in such situations. The most widely used and recognized criterion is Sgarbossa scoring system that includes concordant ST segment elevation > 1 mm ST segment, disconcordant denivelation of ST segment > 1 mm in the leads V1-V3 and disconcordant ST segment elevation > 5 mm with acceptable sensitivity and specificity. In subsequent studies, the sensitivity and specificity increased by replacing the third criterion with ST/S ratio < -0.25. Conclusion. The knowledge of certain electrocardiographic signs in patients with acute coronary syndrome and left bundle branch block increases the chances of early diagnosis and the possibility of better and timely treatment.

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