A critique of the new ST-segment criteria for the diagnosis of acute myocardial infarction in patients with left bundle-branch block

J. E. Madias, Anjan Sinha, R. Ashtiani, H. Agarwal, M. Win, V. K. Narayan

Research output: Contribution to journalArticle

22 Citations (Scopus)

Abstract

Background: Recently, electrocardiogram (ECG) criteria have been proposed for the diagnosis of acute myocardial infarction (AMI) in the presence of left bundle-branch block (LBBB). However, clinical experience indicates that such ECG changes indicative of AMI are occasionally noted in clinically stable patients with LBBB, raising concerns about the specificity of the proposed criteria. Hypothesis: The aim of this study was to evaluate the frequency of ST-segment abnormalities suggestive of AMI in ambulatory patients with cardiovascular disease and chronic LBBB, who did not have an AMI. In addition, the ECG determinants of such ST-segment abnormalities were sought. Methods: The files of all (4,193) patients followed in the outpatient cardiology clinic were reviewed to identify patients with LBBB. Electrocardiograms of these patients were evaluated as to the duration of the QRS complex, frontal QRS axis, amplitude of QRS in leads V1-V3, and the presence and magnitude of ST-segment depression (-ST) in leads V1-V3, and ST-segment elevation (+ST) in leads with predominantly positive or negative QRS complexes. Correlations of these ECG variables were carried out. Results: In 124 patients with LBBB only 1 patient with -ST of 1 mm in leads V1-V3, and 1 patient with +ST of 1 mm in a predominantly positive ECG lead were found; the latter patient also had +ST of 6 mm in V3. Nine patients were detected with ≥5 mm +ST in at least one ECG lead with predominantly negative QRS complex. Regression analysis of amplitude of +STs on corresponding QRS amplitudes in leads V1-V3 yielded Rs of 0.69, 0.68, and 0.69, all with a p value of 0.00005. A similar analysis of the amplitudes of+STs≥5 mm with the corresponding QRSs yielded an R = 0.76 and a p value of 0.0018. Conclusions: Thus, recently proposed ST-segment criteria for the diagnosis of AMI in patients with LBBB are appropriate. However, stable ≥5 mm +STs are occasionally found in leads with predominantly negative QRS complexes, particularly of large amplitude (mean value 46.0, range [28.0-71.0] mm) in the absence of AMI. In such patients presenting with symptoms suggestive of AMI, further non-ECG confirmation of probable underlying AMI should be sought.

Original languageEnglish (US)
Pages (from-to)652-655
Number of pages4
JournalClinical Cardiology
Volume24
Issue number10
StatePublished - 2001
Externally publishedYes

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Bundle-Branch Block
Myocardial Infarction
Electrocardiography
Ambulatory Care Facilities
Cardiology
Cardiovascular Diseases
Regression Analysis

Keywords

  • ECG diagnosis
  • Electrocardiogram
  • Left bundle-branch block
  • Myocardial infarction
  • Thrombolysis

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

A critique of the new ST-segment criteria for the diagnosis of acute myocardial infarction in patients with left bundle-branch block. / Madias, J. E.; Sinha, Anjan; Ashtiani, R.; Agarwal, H.; Win, M.; Narayan, V. K.

In: Clinical Cardiology, Vol. 24, No. 10, 2001, p. 652-655.

Research output: Contribution to journalArticle

Madias, J. E. ; Sinha, Anjan ; Ashtiani, R. ; Agarwal, H. ; Win, M. ; Narayan, V. K. / A critique of the new ST-segment criteria for the diagnosis of acute myocardial infarction in patients with left bundle-branch block. In: Clinical Cardiology. 2001 ; Vol. 24, No. 10. pp. 652-655.
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T1 - A critique of the new ST-segment criteria for the diagnosis of acute myocardial infarction in patients with left bundle-branch block

AU - Madias, J. E.

AU - Sinha, Anjan

AU - Ashtiani, R.

AU - Agarwal, H.

AU - Win, M.

AU - Narayan, V. K.

PY - 2001

Y1 - 2001

N2 - Background: Recently, electrocardiogram (ECG) criteria have been proposed for the diagnosis of acute myocardial infarction (AMI) in the presence of left bundle-branch block (LBBB). However, clinical experience indicates that such ECG changes indicative of AMI are occasionally noted in clinically stable patients with LBBB, raising concerns about the specificity of the proposed criteria. Hypothesis: The aim of this study was to evaluate the frequency of ST-segment abnormalities suggestive of AMI in ambulatory patients with cardiovascular disease and chronic LBBB, who did not have an AMI. In addition, the ECG determinants of such ST-segment abnormalities were sought. Methods: The files of all (4,193) patients followed in the outpatient cardiology clinic were reviewed to identify patients with LBBB. Electrocardiograms of these patients were evaluated as to the duration of the QRS complex, frontal QRS axis, amplitude of QRS in leads V1-V3, and the presence and magnitude of ST-segment depression (-ST) in leads V1-V3, and ST-segment elevation (+ST) in leads with predominantly positive or negative QRS complexes. Correlations of these ECG variables were carried out. Results: In 124 patients with LBBB only 1 patient with -ST of 1 mm in leads V1-V3, and 1 patient with +ST of 1 mm in a predominantly positive ECG lead were found; the latter patient also had +ST of 6 mm in V3. Nine patients were detected with ≥5 mm +ST in at least one ECG lead with predominantly negative QRS complex. Regression analysis of amplitude of +STs on corresponding QRS amplitudes in leads V1-V3 yielded Rs of 0.69, 0.68, and 0.69, all with a p value of 0.00005. A similar analysis of the amplitudes of+STs≥5 mm with the corresponding QRSs yielded an R = 0.76 and a p value of 0.0018. Conclusions: Thus, recently proposed ST-segment criteria for the diagnosis of AMI in patients with LBBB are appropriate. However, stable ≥5 mm +STs are occasionally found in leads with predominantly negative QRS complexes, particularly of large amplitude (mean value 46.0, range [28.0-71.0] mm) in the absence of AMI. In such patients presenting with symptoms suggestive of AMI, further non-ECG confirmation of probable underlying AMI should be sought.

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KW - ECG diagnosis

KW - Electrocardiogram

KW - Left bundle-branch block

KW - Myocardial infarction

KW - Thrombolysis

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