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Diagnosis of acute myocardial infarction in the presence of left bundle branch block
Univ Hosp Basel, CRIB, Basel, Switzerland.ORCID iD: 0000-0003-2173-5738
Royal Brisbane & Womens Hosp, Emergency Dept, Brisbane, Qld, Australia.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.ORCID iD: 0000-0002-5795-0061
Univ Hosp Bern, Dept Cardiol, Bern, Switzerland.
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2019 (English)In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 105, no 20, p. 1559-1567Article in journal (Refereed) Published
Abstract [en]

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 1hour or 2hours 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 0/2hours allows early and accurate diagnosis of AMI in LBBB.

Place, publisher, year, edition, pages
BMJ PUBLISHING GROUP , 2019. Vol. 105, no 20, p. 1559-1567
Keywords [en]
acute coronary syndromes, acute myocardial infarction, ECG, electrocardiogram
National Category
Cardiac and Cardiovascular Systems
Identifiers
URN: urn:nbn:se:uu:diva-397782DOI: 10.1136/heartjnl-2018-314673ISI: 000495077300008PubMedID: 31142594OAI: oai:DiVA.org:uu-397782DiVA, id: diva2:1374317
Available from: 2019-11-29 Created: 2019-11-29 Last updated: 2020-01-07Bibliographically approved

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Lindahl, Bertil

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Nestelberger, ThomasLindahl, BertilParsonage, WilliamWildi, KarinPickering, John William
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