Diagnosis of acute myocardial infarction in the presence of left bundle branch block. Issue 20 (29th May 2019)

• Record Type: Journal Article
• Authors: Nestelberger, Thomas; Cullen, Louise; Lindahl, Bertil; Reichlin, Tobias; Greenslade, Jaimi H; Giannitsis, Evangelos; Christ, Michael; Morawiec, Beata; Miro, Oscar; Martín-Sánchez, Francisco Javier; Wussler, Desiree Nadine; Koechlin, Luca; Twerenbold, Raphael; Parsonage, William; Boeddinghaus, Jasper; Rubini Gimenez, Maria; Puelacher, Christian; Wildi, Karin; Buerge, Tobias; Badertscher, Patrick; DuFaydeLavallaz, Jeanne; Strebel, Ivo; Croton, Lukas; Bendig, Garnet; Osswald, Stefan; Pickering, John William; Than, Martin; Mueller, Christian
• Other Names: author non-byline.; Hillinger Petra author non-byline.; Grimm Karin author non-byline.; Honegger Ursina author non-byline.; Schaerli Nicolas author non-byline.; Kozhuharov Nikola author non-byline.; Shrestha Samyut author non-byline.; Stelzig Claudia author non-byline.; Freese Michael author non-byline.; Sabti Zaid author non-byline.; Walter Joan author non-byline.; Sazgary Lorraine author non-byline.; Kulangara Caroline author non-byline.; Meissner Kathrin author non-byline.; Mueller Deborah author non-byline.; Lopez Beatriz author non-byline.; Salgado Emilio author non-byline.; Adrada Esther Rodríguez author non-byline.; Kawecki Damian author non-byline.; Parenica Jiri author non-byline.; Ganovska Eva author non-byline.; Rentsch Katharina author non-byline.; Buser Andreas author non-byline.; Lohrmann Jens author non-byline.; Bingisser Roland author non-byline.; Shrestha Samyut author non-byline.; Stallone Fabio author non-byline.; Abaecherli Roger author non-byline.; Mccord James author non-byline.; Nowak Richard author non-byline.; Body Richard author non-byline.; Defilippi Christopher R author non-byline.; Christenson Robert H author non-byline.; Panteghini Mauro author non-byline.; Plebani Mario author non-byline.; Verschuren Franck author non-byline.; French John author non-byline.; Weiser Silvia author non-byline.; Dinkel Carina author non-byline.; Keller Dagmar I author non-byline.; Geigy Nicolas author non-byline.;
• Is Part Of: Heart. Volume 105:Issue 20(2019)
• Page Start: 1559
• Page End: 1567
• Publication Date: 2019-05-29
• Subjects: acute coronary syndromes -- acute myocardial infarction -- ECG/electrocardiogram; Heart -- Diseases -- Treatment -- Periodicals; Cardiology -- Periodicals; 616.12
• DOI: 10.1136/heartjnl-2018-314673
• Languages: English
• ISSNs: 1355-6037

Abstract

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.