New Electrocardiographic Algorithm for the Diagnosis of Acute Myocardial Infarction in Patients With Left Bundle Branch Block

Abstract

Background Current electrocardiographic algorithms lack sensitivity to diagnose acute myocardial infarction ( AMI ) in the presence of left bundle branch block. Methods and Results A multicenter retrospective cohort study including consecutive patients with suspected AMI and left bundle branch block, referred for primary percutaneous coronary intervention between 2009 and 2018. Pre‐2015 patients formed the derivation cohort (n=163, 61 with AMI ); patients between 2015 and 2018 formed the validation cohort (n=107, 40 with AMI ). A control group of patients without suspected AMI was also studied (n=214). Different electrocardiographic criteria were tested. A total of 484 patients were studied. A new electrocardiographic algorithm ( BARCELONA algorithm) was derived and validated. The algorithm is positive in the presence of ST deviation ≥1 mm (0.1 mV) concordant with QRS polarity, in any lead, or ST deviation ≥1 mm (0.1 mV) discordant with the QRS , in leads with max (R|S) voltage (the voltage of the largest deflection of the QRS , ie, R or S wave) ≤6 mm (0.6 mV). In both the derivation and the validation cohort, the BARCELONA algorithm achieved the highest sensitivity (93%–95%), negative predictive value (96%–97%), efficiency (91%–94%) and area under the receiver operating characteristic curve (0.92–0.93), significantly higher than previous electrocardiographic rules ( P <0.01); the specificity was good in both groups (89%–94%) as well as the control group (90%). Conclusions In patients with left bundle branch block referred for primary percutaneous coronary intervention , the BARCELONA algorithm was specific and highly sensitive for the diagnosis of AMI , leading to a diagnostic accuracy comparable to that obtained by ECG in patients without left bundle branch block.

Clinical characteristics and the severity of coronary atherosclerosis of different subtypes of bundle‐branch block

“…Therefore, risk stratification of these patients is of much clinical relevance (Jun et al, 2019 ; Khot et al, 2003 ; Messerli Franz et al, 2019 ). Numerous studies have confirmed the direct relationship between the onset of left bundle‐branch block (LBBB) and outcome measures such as all‐cause mortality, cardiac death, acute myocardial infarction (MI), sudden cardiac death, and congestive heart failure, both in patients with and without pre‐existing CAD (Bristow et al, 2004 ; Di Marco et al, 2020 ; Kiehl Erich et al, 2019 ; Moss et al, 2009 ; Witt et al, 2016 ). In recent studies, presence of right bundle‐branch block (RBBB) in patients with different phenotypes of ACS was found associated with cardiovascular disease at baseline, high‐risk clinical features, less cardiac intervention, and poor clinical outcomes (Chan et al, 2016 ; Widimsky et al, 2012 ).…”

Rapid Diagnosis of STEMI Equivalent in Patients With Left Bundle‐Branch Block: Is It Feasible?

“…As mentioned, Sgarbossa et al tested their ECG criteria for identifying patients with creatine kinase MB elevation (not limited to STEMI equivalent), 4 whereas the Barcelona algorithm was tested against relatively lower magnitude of cardiac troponin elevation, which would include virtually all patients with AMI, not just those with OMI. 7 The same holds for the Nestelberger study. 9 , 10 In contrast, Smith et al used a much higher threshold of cardiac troponin elevation that probably restricted the “positive” to patients with true STEMI equivalence.…”

“…The Barcelona algorithm includes ST deviation >1 mm concordant with QRS polarity in any ECG lead or ST deviation >1 mm discordant with QRS polarity; in any lead with maximal QRS (R or S wave) voltage <6 mm is considered predictive of STEMI equivalent. 7 This algorithm was tested in a relatively large cohort of patients referred for primary percutaneous coronary intervention (n=484) and reported better accuracy than the Sgarbossa and Smith criteria. Yet, it has not been validated in an independent cohort.…”

„STEMI mimics“

“…Entgegen der früheren Lehrmeinung ist es möglich, Ischämiezeichen im EKG in dieser Konstellation zu erkennen. Hierzu können die modifizierten Sgarbossa-Kriterien [ 34 ] oder die allerdings noch nicht endgültig validierten Barcelona-Kriterien herangezogen werden [ 7 ].…”