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Diagnosis of myocardial infarction and ischemia in the setting of bundle branch block and cardiac pacing

Diagnose von Myokardinfarkt und Ischämie bei Vorliegen eines Schenkelblocks und kardialer Stimulation

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Abstract

The diagnosis of myocardial infarction (MI) in the presence of left bundle branch block (LBBB) or during ventricular pacing (VP) is challenging because of inherent changes in the sequence of ventricular depolarization and repolarization associated with both conditions. Although LBBB and right ventricular (RV) pacing may both produce abnormalities in the ECG, it is often possible to diagnose an acute MI (AMI) or an old MI based on selected morphologic changes. Primary ST-segment changes scoring 3 points or greater according to the Sgarbossa criteria are highly predictive of an AMI in patients with LBBB or RV pacing. The modified Sgarbossa criteria are useful for the diagnosis of AMI in patients with LBBB; however, these criteria have not yet been studied in the setting of RV pacing. Although changes of the QRS complex are not particularly sensitive for the diagnosis of an old MI in the setting of LBBB or RV pacing, the qR complex and Cabrera sign are highly specific for the presence of an old infarct. Diagnosing AMI in the setting of biventricular (BiV) pacing is challenging. To date there is minimal evidence suggesting that the traditional electrocardiographic criteria for diagnosis of AMI in bundle branch block may be applicable to patients with BiV pacing and positive QRS complexes on their ECG in lead V1. This report is a careful review of the electrocardiographic criteria facilitating the diagnosis of acute and remote MI in patients with LBBB and/or VP.

Zusammenfassung

Die Diagnose eines Myokardinfarkts (MI) bei Vorliegen eines Linksschenkelblocks („left bundle branch block“, LBBB) oder während ventrikulärer Stimulation (VP) stellt eine Herausforderung dar aufgrund der inhärenten Sequenzveränderungen bei der ventrikulären Depolarisation und Repolarisation, welche mit beiden Erkrankungen assoziiert sind. Obwohl ein LBBB wie auch die rechtsventrikuläre (RV) Stimulation Abnormalitäten im EKG hervorrufen kann, ist es häufig möglich, auf der Basis bestimmter morphologischer Veränderungen einen akuten MI (AMI) oder einen zurückliegenden MI zu diagnostizieren. Primäre Veränderungen des ST-Segments von ≥3 Punkten gemäß den Sgarbossa-Kriterien stellen einen signifikanten Prädiktor eines AMI bei Patienten mit LBBB und RV-Stimulation dar. Die modifizierten Sgarbossa-Kriterien sind bei der Diagnosestellung eines AMI bei Patienten mit LBBB nützlich; diese Kriterien wurden im Rahmen einer RV-Stimulation noch nicht untersucht. Veränderungen des QRS-Komplexes sind bei der Diagnostik eines zurückliegenden MI bei Vorliegen eines LBBB oder RV-Stimulation nicht besonders sensitiv. Jedoch sind der QR-Komplex sowie das Cabrera-Zeichen hochspezifisch für das Vorliegen eines zurückliegenden Infarkts. Die Diagnose eines AMI bei Vorliegen einer biventrikulären (BiV) Stimulation ist schwierig. Bis heute gibt es nur sehr geringe Evidenz, die belegt, dass die traditionellen elektrokardiographischen Kriterien für die Diagnose eines AMI mit Schenkelblock bei Patienten mit BiV-Stimulation und positiven QRS-Komplexen im EKG in der V1-Elektrode anwendbar ist. Dieser Bericht beinhaltet ein sorgfältiges Review der elektrokardiographischen Kriterien, um die Diagnose eines akuten und zurückliegenden MI bei Patienten mit LBBB und/oder VP zu erleichtern.

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References

  1. Hands ME, Cook EF, Stone PH et al (1988) Electrocardiographic diagnosis of myocardial infarction in the presence of complete left bundle branch block. Am Heart J 116:23–31

    Article  CAS  PubMed  Google Scholar 

  2. Sgarbossa EB, Pinski SL, Barbagelata A et al (1996) 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 334:481–487

    Article  CAS  PubMed  Google Scholar 

  3. Sgarbossa EB (1996) Recent advances in the electrocardiographic diagnosis of myocardial infarction: left bundle branch block and pacing. Pacing Clin Electrophysiol 19:1370–1379

    Article  CAS  PubMed  Google Scholar 

  4. Sgarbossa EB (2000) Value of the ECG in suspected acute myocardial infarction with left bundle branch block. J Electrocardiol 33 (Suppl):88–92

    Google Scholar 

  5. Wong CK, French JK, Aylward PE et al (2005) 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 46:29–38

    Article  PubMed  Google Scholar 

  6. Wackers FJ (1987) The diagnosis of myocardial infarction in the presence of left bundle branch block. Cardiol Clin 5:393–401

    CAS  PubMed  Google Scholar 

  7. Wellens HJ (1996) Acute myocardial infarction and left bundle-branch block – can we lift the veil? N Engl J Med 334:528–529

    Article  CAS  PubMed  Google Scholar 

  8. Gula LJ, Dick A, Massel D (2003) Diagnosing acute myocardial infarction in the setting of left bundle branch block: prevalence and observer variability from a large community setting. Coron Artery Dis 14:387–393

    PubMed  Google Scholar 

  9. Wilson FN, Finch R (1923) The effect of drinking iced-water upon the form of the T deflection of the electrocardiogram. Heart 10:275–287

    Google Scholar 

  10. Wilson FN, Macleod AG, Barker PS (1931) The T deflection of the electrocardiogram. Trans Assoc Am Physicians 46:29–38

    Google Scholar 

  11. Burgess MJ, Green LS, Millar K, Wyatt R, Abildskov JA (1972) The sequence of normal ventricular recovery. Am Heart J 84:660–669

    Article  CAS  PubMed  Google Scholar 

  12. Franz MR, Bargheer K, Rafflenbeul W, Haverich A, Lichtlen PR (1987) Monophasic action potential mapping in human subjects with normal electrocardiograms: direct evidence for the genesis of the T wave. Circulation 75:379–386

    Article  CAS  PubMed  Google Scholar 

  13. Spach MS, Barr RC (1975) Ventricular intramural and epicardial potential distributions during ventricular activation and repolarization in the intact dog. Circ Res 37:243–257

    Article  CAS  PubMed  Google Scholar 

  14. Barold SS, Herweg B (2006) Electrocardiographic diagnosis of myocardial infarction during left bundle branch block. Cardiol Clin 24:377–385

    Article  PubMed  Google Scholar 

  15. Kennamer RP (1956) Myocardial infarction complicated by left bundle branch block. Am Heart J 51:78–90

    Article  CAS  PubMed  Google Scholar 

  16. Wackers FJ (1983) Complete left bundle branch block: is the diagnosis of myocardial infarction possible? Int J Cardiol 2:521–529

    Article  CAS  PubMed  Google Scholar 

  17. Sclarovsky S, Sagie A, Strasberg B et al (1988) Ischemic blocks during early phase of anterior myocardial infarction: correlation with ST-segment shift. Clin Cardiol 11:757–762

    Article  CAS  PubMed  Google Scholar 

  18. Cannon A, Freedman SB, Bailey BP, Bernstein L (1989) ST-segment changes during transmural myocardial ischemia in chronic left bundle branch block. Am J Cardiol 64:1216–1217

    Article  CAS  PubMed  Google Scholar 

  19. Stark KS, Krucoff MW, Schryver B, Kent KM (1991) Quantification of ST-segment changes during coronary angioplasty in patients with left bundle branch block. Am J Cardiol 67:1219–1222

    Article  CAS  PubMed  Google Scholar 

  20. Smith SW, Dodd KW, Henry TD, Dvorak DM, Pearce LA (2012) 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 60:766–776

    Article  PubMed  Google Scholar 

  21. Li SF, Walden PL, Marcilla O, Gallagher EJ (2000) Electrocardiographic diagnosis of myocardial infarction in patients with left bundle branch block. Ann Emerg Med 36:561–565

    Article  CAS  PubMed  Google Scholar 

  22. Sokolove PE, Sgarbossa EBA, Gelber EAR et al (2000) Interobserver variability in the electrocardiographic diagnosis of acute myocardial infarction in patients with left bundle branch block. Ann Emerg Med 36:566–571

    Article  CAS  PubMed  Google Scholar 

  23. Gunnarsson G, Eriksson P, Dellborg M (2001) ECG criteria in diagnosis of acute myocardial infarction in the presence of left bundle branch block. Int J Cardiol 2001:167–174

    Article  Google Scholar 

  24. Kontos MC, McQueen RH, Jesse RL, Tatum JL, Ornato JP (2001) Can myocardial infarction be rapidly identified in emergency department patients who have left bundle branch block? Ann Emerg Med 37:431–438

    Article  CAS  PubMed  Google Scholar 

  25. Shlipak MG, Lyons WL, Go AS, Chou TM, Evans GT, Browner WS (1999) Should the electrocardiogram be used to guide therapy for patients with left bundlebranch block and suspected myocardial infarction? JAMA 281:714–719

    Article  CAS  PubMed  Google Scholar 

  26. Edhouse JA, Sakr M, Angus J, Morris FP (1999) Suspected myocardial infarction and left bundle branch block: electrocardiographic indicators of acute ischaemia. J Accid Emerg Med 16:331–335

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Thygesen K, Alpert JS, Jaffe AS et al (2012) Third universal definition of myocardial infarction. J Am Coll Cardiol 60:1581–1598

    Article  PubMed  Google Scholar 

  28. Alpert JS, Thygesen K, Antman E, Bassand JP (2000) Myocardial infarction redefined-a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol 36:959–969

    Article  CAS  PubMed  Google Scholar 

  29. Besoaín-Santander M, Gómez-Ebensperguer G (1960) Electrocardiographic diagnosis of myocardial infarction in cases of complete left bundle branch block. Am Heart J 60:886–897

    Article  Google Scholar 

  30. Doucet P, Walsh TJ, Massie E (1966) A vectorcardiographic and electrocardiographic study of left bundle branch block with myocardial infarction. Am J Cardiol 17:171–179

    Article  CAS  PubMed  Google Scholar 

  31. Cabrera E, Friedland C (1953) La onda de activación ventricular en el bloqueo de rama izquierda con infarto: un nuevo signo electrocardiográfico. Arch Inst Cardiol Mex 23:441–460

    CAS  PubMed  Google Scholar 

  32. Hands MECE, Stone PH et al (1998) Electrocar-diographic diagnosis of myocardial infarction in the presence of complete left bundle branch block. Am Heart J 116:23–31

    Article  Google Scholar 

  33. Coumel P (1987) Diagnostic significance of the QRS wave form in patients with ventricular tachycardia. Cardiol Clin 5:527–540

    CAS  PubMed  Google Scholar 

  34. Josephson ME, Miller JM (1990) Endocardial and epicardial recordings. Correlation of twelve-lead electrocardiograms at the site of origin of ventricular tachycardia. Ann N Y Acad Sci 601:128–147

    Article  CAS  PubMed  Google Scholar 

  35. Madias JE (2004) The nonspecificity of ST-segment elevation 〉 or =5.0 mm in V1–V3 in the diagnosis of acute myocardial infarction in the presence of ventricular paced rhythm. J Electrocardiol 37:135–139

    Article  PubMed  Google Scholar 

  36. Sgarbossa EB, Pinski SL, Gates KB, Wagner GS (1996) Early electrocardiographic diagnosis of acute myocardial infarction in the presence of ventricular paced rhythm. GUSTO-I investigators. Am J Cardiol 77:423–424

    Article  CAS  PubMed  Google Scholar 

  37. Caldera AE, Bryce M, Kotler M, Braitman LE, Spielman S (2002) Angiographic significance of a discordant ST-segment elevation of R5 millimeters in patients with ventricularpaced rhythm and acute myocardial infarction. Am J Cardiol 90:1240–1243

    Article  PubMed  Google Scholar 

  38. Barold SS (2000) Diagnosis of myocardial ischemia during ventricular pacing. Pacing Clin Electrophysiol 23:1060–1061

    Article  CAS  PubMed  Google Scholar 

  39. Manyari DE, Klein GJ, Kostuk WJ (1983) Electrocardiographic recognition of variant angina during permanent pacing. Pacing Clin Electrophysiol 6:99–103

    Article  CAS  PubMed  Google Scholar 

  40. Mery D, Dagran O, Bailly E, Grolleau R, Puech P (1979) First and second degree blocks (Wenckebach type) during right ventricular stimulation in the course of Prinzmetal’s angina. Arch Mal Coeur Vaiss 72:385–390

    CAS  PubMed  Google Scholar 

  41. Kilic H, Atalar E, Ozer N et al (2008) Early electrocardiographic diagnosis of acute coronary ischemia on the paced electrocardiogram. Int J Cardiol 130:14–18

    Article  PubMed  Google Scholar 

  42. Barold SS, Falkoff MD, Ong LS, Heinle RA (1987) Electrocardiographic diagnosis of myocardial infarction during ventricular pacing. Cardiol Clin 5:403–417

    CAS  PubMed  Google Scholar 

  43. Barold SS, Herweg B, Giudici M (2005) Electrocardiographic follow-up of biventricular pacemakers. Ann Noninvasive Electrocardiol 10:231

    Article  PubMed  Google Scholar 

  44. Tzeis S, Andrikopoulos G, Asbach S et al (2014) Electrocardiographic identification of prior myocardial infarction during right ventricular pacing-effect of septal versus apical pacing. Int J Cardiol 177:977–981

    Article  PubMed  Google Scholar 

  45. Barold SS, Herweg B (2007) Electrocardiographic diagnosis of myocardial infarction and ischemia during right ventricular pacing. J Electrocardiol 40:164–167

    Article  PubMed  Google Scholar 

  46. Kochiadakis GE, Kaleboubas MD, Igoumenidis NE, Skalidis EI, Simantirakis EN, Chrysostomakis SI, Vardas PE. (2002) Electrocardiographic appearance of old myocardial infarction in paced patients. Pacing Clin Electrophysiol 25:1061–1065.

    Article  PubMed  Google Scholar 

  47. Barold SS, Giudici MC, Herweg B, Curtis AB (2006) Diagnostic value of the 12-lead electrocardiogram during conventional and biventricular pacing for cardiac resynchronization. Cardiol Clin 24:471–490 (x)

    Article  PubMed  Google Scholar 

  48. Ukena C, Mahfoud F, Buob A, Bohm M, Neuberger HR (2012) ST-elevation during biventricular pacing. Europace 14:609–611

    Article  PubMed  Google Scholar 

  49. Karumbaiah K, Omar B (2013) ST-elevation myocardial infarction in the presence of biventricular paced rhythm. J Emerg Med 45:e35–e40

    Article  PubMed  Google Scholar 

  50. Chaterjee K, Harris A, Davies G, Leatham A (1969) Electrocardiographic changes subsequent to artificial ventricular depolarization. Br Heart J 31:770–779

    Article  Google Scholar 

  51. Goldberger JJ, Kadish AH (1999) Cardiac memory. Pacing Clin Electrophysiol 22:1672–1679

    Article  CAS  PubMed  Google Scholar 

  52. Rosen MR (2000) What is cardiac memory? J Cardiovasc Electrophysiol 11:1289–1293

    Article  CAS  PubMed  Google Scholar 

  53. Patberg KW, Shvilkin A, Plotnikov AN, Chandra P, Josephson ME, Rosen MR (2005) Cardiac memory: mechanisms and clinical implications. Heart Rhythm 2:1376–1382

    Article  PubMed  Google Scholar 

  54. Goyal R, Syed ZAM, Souza PSJ et al (1998) Changes in cardiac repolarization following short periods of ventricular pacing. J Cardiovasc Electrophysiol 9:269–280

    Article  CAS  PubMed  Google Scholar 

  55. Plotnikov AN, Yu H, Geller JC et al (2003) Role of L‑type calcium channels in pacing-induced short-term and long-term cardiac memory in canine heart. Circulation 107:2844–2849

    Article  CAS  PubMed  Google Scholar 

  56. Patberg KW, Obreztchikova MN, Giardina SF et al (2005) The cAMP response element binding protein modulates expression of the transient outward current: implications for cardiac memory. Cardiovasc Res 68:259–267

    Article  CAS  PubMed  Google Scholar 

  57. Shvilkin A, Ho KK, Rosen MR, Josephson ME (2005) T‑vector direction differentiates postpacing from ischemic T‑wave inversion in precordial leads. Circulation 111:969–974

    Article  PubMed  Google Scholar 

  58. Barold SS, Herweg B, Curtis AB (2006) Electrocardiographic diagnosis of myocardial infarction and ischemia during cardiac pacing. Cardiol Clin 24(ix):387–399

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Cardiovascular Disease, University of South Florida Morsani College of Medicine, South Tampa Campus (5th floor), Two Tampa General Circle, FL 33606, Tampa, FL, USA

    B. Herweg MD, FACC, FHRS & M. B. Marcus MD

  2. Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA

    S. S. Barold MD, FACC

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  1. B. Herweg MD, FACC, FHRS
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  2. M. B. Marcus MD
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  3. S. S. Barold MD, FACC
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Correspondence to B. Herweg MD, FACC, FHRS, M. B. Marcus MD or S. S. Barold MD, FACC.

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B. Herweg, M.B. Marcus, and S. S. Barold state that there are no conflicts of interest.

The accompanying manuscript does not include studies on humans or animals.

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Herweg, B., Marcus, M.B. & Barold, S.S. Diagnosis of myocardial infarction and ischemia in the setting of bundle branch block and cardiac pacing. Herzschr Elektrophys 27, 307–322 (2016). https://doi.org/10.1007/s00399-016-0439-1

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