WHICH PATIENTS WITH SUSPECTED MYOCARDIAL ISCHEMIA AND BUNDLE BRANCH BLOCK SHOULD RECEIVE EMERGENCY REPERFUSION THERAPY ?
Abstract
The electrocardiogram is one of the first test directing reperfusion therapy for patients with acute myocardial infarction, depending on the presence or absence of ST-segment elevation. The presence of left or right bundle branch block on an electrocardiogram is frequently encountered in our clinical practice and their hemodynamic implications are increasingly being studied. However, the presence of left bundle block is usually associated with a more reserved prognosis compared to normal intraventricular conduction. In the same time, the presence of right bundle branch block is often considered benign in the absence of a cardiac pathology. Also, left bundle branch block has historically prevented accurate recognition of acute myocardial infarction. This may lead to a poor allocation of reperfusion therapy and secondary to a suboptimal patient outcome. Over the past 20 years, the management guidelines for these patients have shifted from one extreme to the other, considering the limited knowledge on this topic. In this context, the new European Society of Cardiology guideline recommends for patients with persistent ischemic symptoms and right bundle-branch block, a primary percutaneous coronary intervention strategy, but the level of evidence is not high. Considering that new-onset right bundle branch block may indicate the proximal occlusion of the left anterior descendent artery and large infarction, which may cause severe heart failure, malignant arrhythmias, complete atrioventricular block, an emergency reperfusion therapy may prevent all these. This is probably the reason why the current reperfusion therapy has changed the overall incidence and significance of right bundle branch block in acute myocardial infarction. In this clinical and epidemiological context, we consider justified to reanalyze and review the significance of left and right bundle branch block in the reperfusion therapy era.
References
2. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. J Am Coll Cardiol 2014; 64:e139-e228.
3. Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003; 349:2128-2135.
4. Thygesen K, Alpert JS, Jaffe AS, et al. ESC Scientific Document Group. Fourth universal definition of myocardial infarction. Eur Heart J 2018; 40(3): 237-269.
5. Wong CK, French JK, Aylward PE, et al. Patients with prolonged ischemic chest pain and presumed-new left bundle branch block have heterogeneous outcomes depending on the presence of ST-segment changes. J Am Coll Cardiol 2005; 46(1): 29-38.
6. Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med 1996; 334(8): 481-487.
7. Smith SW, Dodd KW, Henry TD, et al.Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Ann Emerg Med 2012; 60(6): 766-776.
8. Sørensen JT, Stengaard C, Sørensen CA, et al. Diagnosis and outcome in a prehospital cohort of patients with bundle branch block and suspected acute myocardial infarction. Eur Heart J Acute Car-diovasc Care 2013; 2(2): 176-181.
9. Lambrecht S, Sarkisian L, Saaby L, et al. Different causes of death in patients with myocardial infarc-tion type 1, type 2 and myocardial injury. Am J Med 2018; 131: 548-554.
10. Chapman AR, Shah ASV, Lee KK, et al. Long-term outcomes in patients with type 2 myocardial infarction and myocardial injury. Circulation 2018; 137: 1236-1245.
11. Widimsky P, Rohac F, Stasek J, et al. Primary angioplasty in acute myocardial infarction with right bundle branch block: Should new onset right bundle branch block be added to future guidelines as an indication for reperfusion therapy? Eur Heart J 2012; 33: 86-95.
12. Roth A, Miller HI, Glick A, Barbash GI, Laniado S. Rapid resolution of new right bundle branch block in acute anterior myocardial infarction patients after thrombolytic therapy. Pacing Clin Electrophysiol 1993; 16(1): 13-18.
13. Wang J, Luo H, Kong C, et al. Prognostic value of new-onset right bundle-branch block in acute myocardial infarction patients: a systematic review and meta-analysis. Peer J 2018;6:e4497.
14. Sgarbossa EB. Value of the ECG in suspected acute myocardial infarction with left bundle branch block. J Electrocardiol 2000; 33 Suppl: 87-92.
15. Neeland IJ1, Kontos MC, de Lemos JA. Evolving considerations in the management of patients with left bundle branch block and suspected myocardial infarction. J Am Coll Cardiol 2012; 60(2): 96-105.
16. Cai Q, Mehta N, Sgarbossa EB, et al. The left bundle-branch block puzzle in the 2013 ST-elevation myocardial infarction guideline: from falsely declaring emergency to denying reperfusion in a high-risk population. Are the Sgarbossa Criteria ready for prime time? Am Heart J 2013;166(3): 409-413.
17. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2018; 39: 119-177.
18. Pera VK, Larson DM, Sharkey SW, et al. New or presumed new left bundle branch block in patients with suspected ST-elevation myocardial infarction. Eur Heart J Acute Cardiovasc Care 2018; 7(3): 208-217.
19. Dodd KW, Elm KD, Smith SW. Comparison of the QRS Complex, ST-segment, and T-wave among patients with left bundle branch block with and without acute myocardial infarction. J Emerg Med 2016; pii: S0736-4679(16)00213-4.
20. Engel TR, Wolf NM. Left bundle branch block does not mean left coronary artery block. J Am Coll Cardiol 2013; 62(11): 968-969.
21. Arsenescu Georgescu C, Anghel L. Long term assessment of the biological profile in patients with acute myocardial infarction and left bundle branch block. Rev Chim (Buc) 2017; 68(11): 2682-2684.
22. Cuciureanu DI, Constantinescu VA, Stătescu C, et al. Antithrombotic therapy in patients with stroke: an observational study. Rev Chim (Buc) 2019; 70(4): 1283-1287.
23. Meyers HP, Limkakeng AT Jr, Jaffa EJ, et al. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study. Am Heart J 2015; 170(6): 1255-1264.
24. Larson DM, Menssen KM, Sharkey SW, et al. “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA 2007; 298(23): 2754-2760.
25. Chang AM, Shofer FS, Tabas JA, et al. Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients. Am J Emerg Med 2009; 27(8): 916-921.
26. Anghel L, Arsenescu Georgescu C. Prevalence of cardiovascular risk factors among patients with acute myocardial infarction and new left bundle branch block in North East Romania. Rev Chim (Buc) 2018; 69(6): 1554-1557.
27. Arsenescu Georgescu C, Anghel L. The significance of new left bundle branch block complicating acute myocardial infarction. Rev Chim (Buc) 2018; 69(1): 144-147.
28. Farré N, Mercè J, Camprubí M, et al. Prevalence and outcome of patients with left bundle branch block and suspected acute myocardial infarction. Int J Cardiol 2015; 182: 164-165.
29. Alkindi F, El-Menyar A, Al-Suwaidi J, et al. Left bundle branch block in acute cardiac events: insights from a 23-year registry. Angiology 2015; 66(9): 811-817.
30. Nestelberger T, Cullen L, Lindahl B, et al. Diagnosis of acute myocardial infarction in the presence of left bundle branch block. Heart 2019; 105(20): 1559-1567.
31. Stătescu C, Sascău R, Anghel L, Butcovan D. Morphological diagnosis of myocardial infarction - in the light of the current clinical classification. Rev Med Chir Soc Med Nat Iași 2019; 123(4): 708-716.
32. Butcovan D, Tinică G, Stătescu C, et al. Immunohistochemical interplay in associated large vessel vasculitis and consequent ascending aortic aneurysm and review of literature. Rev Chim (Buc) 2019; 70(12): 4348-4354.
33. Zota IM, Sascău R, Stătescu C, et al. Quality of life in moderate-severe OSA patients from North-Eastern Romania. RCIS 2020; 68(1): 250-260.
34. Xiang L, Zhong A, You T, Chen J, Xu W, Shi M. Prognostic significance of right bundle branch block for patients with acute myocardial infarction: a systematic review and meta-analysis. Med SciMonit 2016; 22: 998-1004.
35. Lévy S. Bundle branch blocks and/or hemiblocks complicating acute myocardial ischemia or infarction. J Interv Cardiac Electrophysiol 2018; 52(3): 287-292.
36. Li J, Li X, Dong S, Yang Y, Chu Y. Clinical characteristics and value in early reperfusion therapy for new onset right bundle branch block in patients with acute myocardial infarction. Exp Ther Med 2018; 15(3): 2620-2626.
37. Neumann JT, Sörensen NA, Rübsamen N, et al. Right bundle branch block in patients with suspected myocardial infarction. Eur Heart J Acute Cardiovasc Care 2019; 8(2): 161-166.
38. Timóteo AT, Mendonça T, Aguiar Rosa S, et al. Prognostic impact of bundle branch block after acute coronary syndrome. Does it matter if it is left of right ? Int J Cardiol Heart Vasc 2018; 22: 31-34.
39. Shaikh S, Al-Sadawi M, Dogar MU, et al. New onset right bundle branch block in acute coronary syndrome and high-grade stenosis: a case series. Scifed J Cardiol 2019; 3(1) pii: 23.
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