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Observational Study
. 2019 Oct;105(20):1559-1567.
doi: 10.1136/heartjnl-2018-314673. Epub 2019 May 29.

Diagnosis of acute myocardial infarction in the presence of left bundle branch block

Thomas Nestelberger #  1 , Louise Cullen #  2 , Bertil Lindahl  3 , Tobias Reichlin  4 , Jaimi H Greenslade  2 , Evangelos Giannitsis  5 , Michael Christ  6 , Beata Morawiec  7 , Oscar Miro  8 , Francisco Javier Martín-Sánchez  9 , Desiree Nadine Wussler  1 , Luca Koechlin  1 , Raphael Twerenbold  1 , William Parsonage  10 , Jasper Boeddinghaus  1 , Maria Rubini Gimenez  1 , Christian Puelacher  1 , Karin Wildi  1 , Tobias Buerge  1 , Patrick Badertscher  1 , Jeanne DuFaydeLavallaz  1 , Ivo Strebel  1 , Lukas Croton  1 , Garnet Bendig  11 , Stefan Osswald  1 , John William Pickering  12 , Martin Than  13 , Christian Mueller  1 ; APACE, ADAPT and TRAPID-AMI Investigators
Collaborators, Affiliations
Observational Study

Diagnosis of acute myocardial infarction in the presence of left bundle branch block

Thomas Nestelberger et al. Heart. 2019 Oct.

Abstract

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

Trial registration number: APACE: NCT00470587; ADAPT: ACTRN12611001069943; TRAPID-AMI: RD001107;Results.

Keywords: ECG/electrocardiogram; acute coronary syndromes; acute myocardial infarction.

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Conflict of interest statement

Competing interests: CM has received research grants from the Swiss National Science Foundation and the Swiss Heart Foundation, the European Union, the Cardiovascular Research Foundation Basel, 8sense, Abbott, Alere, AstraZeneca, Beckman Coulter, bioMerieux, BRAHMS, Critical Diagnostics, Nanosphere, Roche, Siemens, Singulex and the University Hospital Basel, as well as speaker or consulting honoraria from Abbott, Alere, AstraZeneca, BG Medicine, bioMerieux, BMS, Boehringer Ingelheim, BRAHMS, Cardiorentis, Daiichi Sankyo, Novartis, Roche, Sanofi, Singulex and Siemens. LC reports grants from Roche and from Abbott, during the conduct of the study, grants from Roche, grants and personal fees from Abbott Diagnostics, grants from Siemens, grants from Radiometer, personal fees from AstraZeneca, and grants from Alere, outside the submitted work. BL has served as a consultant for Roche Diagnostics, Beckman Coulter, Siemens Healthcare Diagnostics, Radiometer Medical, bioMérieux Clinical Diagnostics, Philips Healthcare and Fiomi Diagnostics. TR has received research grants from the Swiss National Science Foundation (PASMP3-136995), the Swiss Heart Foundation, the University of Basel, the Professor Max Cloetta Foundation, and the Department of Internal Medicine, University Hospital Basel, as well as speaker’s honoraria from BRAHMS and Roche. EG has received honoraria for lectures from Roche Diagnostics, BRAHMS, Thermo Fisher and Mitsubishi Chemical Europe. MC has received research support and speaking honoraria from Roche, Thermo Fisher and Novartis. RT reports speaker honoraria from BRAHMS and Roche. WP reports grants from Roche and from Abbott, during the conduct of the study, and grants from Roche, grants and personal fees from Abbott Diagnostics, grants from Siemens, grants from Radiometer, personal fees from AstraZeneca, non-financial support from Bayer, personal fees from Hospira and grants from Alere, outside the submitted work. MRG has received speaking honoraria from Abbott and a research grant from the Swiss Heart Foundation. JB has received speaking honoria from Siemens. GB is an employee of Roche Diagnostics. JWP is supported by a Senior Research Fellowship from the Canterbury Medical Research Foundation, Emergency Care Foundation and Canterbury District Health. All other authors declare that they have no conflict of interest with this study.

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