Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients

Chang, Anna Marie; Shofer, Frances S.; Tabas, Jeffrey A.; Magid, David J.; McCusker, Christine M.; Hollander, Judd E.

doi:10.1016/j.ajem.2008.07.007

Cited by 61 publications

(35 citation statements)

References 28 publications

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“…In addition, although we classified patients with a new LBBB as having AMI, newer data indicate that this may not be the case. 35 (One patient in the validation group had a new LBBB but had a complete circumflex artery occlusion and received a stent during angiography.). Although the ACS rate decreased between the derivation and validation cohorts, identical outcomes were used to minimize verification bias.…”

Section: Limitationsmentioning

confidence: 99%

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Scheuermeyer

Wong

et al. 2014

CJEM

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Objectives: Current guidelines emphasize that emergency department (ED) patients at low risk for potential ischemic chest pain cannot be discharged without extensive investigations or hospitalization to minimize the risk of missing acute coronary syndrome (ACS). We sought to derive and validate a prediction rule that permitted 20 to 30% of ED patients without ACS safely to be discharged within 2 hours without further provocative cardiac testing. Methods: This prospective cohort study enrolled 1,669 chest pain patients in two blocks in 2000-2003 (development cohort) and 2006 (validation cohort). The primary outcome was 30-day ACS diagnosis. A recursive partitioning model incorporated reliable and predictive cardiac risk factors, pain characteristics, electrocardiographic findings, and cardiac biomarker results. Results: In the derivation cohort, 165 of 763 patients (21.6%) had a 30-day ACS diagnosis. The derived prediction rule was 100.0% sensitive and 18.6% specific. In the validation cohort, 119 of 906 patients (13.1%) had ACS, and the prediction rule was 99.2% sensitive (95% CI 95.4-100.0) and 23.4% specific (95% CI 20.6-26.5). Patients have a very low ACS risk if arrival and 2-hour troponin levels are normal, the initial electrocardiogram is nonischemic, there is no history of ACS or nitrate use, age is , 50 years, and defined pain characteristics are met. The validation of the rule was limited by the lack of consistency in data capture, incomplete follow-up, and lack of evaluation of the accuracy, comfort, and clinical sensibility of this clinical decision rule. Conclusion: The Vancouver Chest Pain Rule may identify a cohort of ED chest pain patients who can be safely discharged within 2 hours without provocative cardiac testing. Further validation across other centres with consistent application and comprehensive and uniform follow-up of all eligible and enrolled patients, in addition to measuring and reporting the accuracy of and comfort level with applying the rule and the clinical sensibility, should be completed prior to adoption and implementation. RÉ SUMÉObjectif: D'aprè s les lignes directrices actuelles, on ne peut renvoyer du service des urgences (SU) les patients qui souffrent de douleurs thoraciques de nature probablement isché mique mais qui connaissent un faible risque de maladie cardiaque sans d'abord leur faire subir une exploration approfondie ou sans les hospitaliser afin de ré duire le plus possible le risque de syndrome coronarien aigu (SCA) passé inaperç u. Aussi avons-nous tenté d'é laborer et de valider une rè gle pré visionnelle qui permettrait de renvoyer en toute sé curité de 20 à 30% des patients ne souffrant pas d'un SCA au cours des 2 heures suivant leur arrivé e au SU, et ce, sans leur faire subir d'autres é preuves d'exploration cardiaque. August 20, 2012) suggest over 600,000 annual ED visits. Between 2 and 5% of patients with acute coronary syndrome (ACS) may be discharged with an incorrect non-ACS diagnosis and no further follow-up, 3,4 leading to adverse patient ...

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Section: Limitationsmentioning

confidence: 99%

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Scheuermeyer

Wong

et al. 2014

CJEM

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“…13 The presence of LBBB also has been shown to be a poor predictor for infarction. 14 The most recent ACCF/AHA guideline on STEMI management notes that LBBB may interfere with the ability to detect STEMI and should not be used in isolation to diagnose AMI. 1 Because patients with LBBB, however, not uncommonly do present with acute coronary syndrome, the clinician must remain vigilant.…”

Section: Left Bundle Branch Blockmentioning

confidence: 99%

Chameleons

Nable

Lawner

2015

Emergency Medicine Clinics of North America

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“…Past ED studies show that the incidence of AMI in ED chest pain patients, as diagnosed by CK-MB, is low, at about 13 % [47,48]. More recently, Chang et al [49] found the incidence of troponin-diagnosed AMI in patients with LBBB at 5.2 % and with new LBBB at 7.3 %. As approximately 30 % of troponin-diagnosed AMI patients have STEMI [50], it is probable that only about 2-4 % of patients with chest pain and LBBB have STEMI.…”

Section: Left Bundle Branch Block and Amimentioning

confidence: 99%

Updates on the Electrocardiogram in Acute Coronary Syndromes

Smith

2012

Curr Emerg Hosp Med Rep

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The electrocardiogram (ECG) is the initial test in patients with suspected ACS. The ECG is the defining element of ST-segment elevation myocardial infarction (STEMI). Its most important use is in the detection of acute coronary obstruction, and it is the most important, cost-effective, and immediately available initial test in the decision for emergency reperfusion therapy. There is a recent interest in refining the sensitivity and specificity of the ECG for coronary occlusion, and thus for identifying subtle STEMI, as well as in recognizing pseudoinfarction patterns and thus avoiding false positive cath lab activations. Studies assessing the accuracy of cath lab activation, the differentiation of precordial ST-segment elevation due to normal variant from that of anterior STEMI, the diagnosis of STEMI in the presence of left bundle branch block, the differentiation of benign inferior ST-segment elevation from that of inferior STEMI, and the importance of ST-segment elevation in lead aVR will be discussed.

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Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients

Cited by 61 publications

References 28 publications

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Chameleons

Updates on the Electrocardiogram in Acute Coronary Syndromes

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