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It is important to remember that LBBB and paced rhythms DO NOT obviate the ability to diagnose acute coronary occlusion. It is clear that the Sgarbossa and modified Sgarbossa criteria are very specific (but not sensitive) and may be used to help identify occlusion MI in patients with LBBB or paced rhythms. This is supported by the ESC guidelines (Ibanez et al., 2017). More recently, Di Marco et al. has proposed a new Barcelona algorithm the has much greater reported sensitivity and comparable specificity for acute OMI in patients with LBBB:
Barcelona Criteria for OMI:
Barcelona Criteria for OMI:
Concordant ST deviation (≥ 1 mm) is abnormal in any lead
Extends Sgarbossa rule of concordant ST depression in V1-V3 to any other lead
Discordant ST deviation (≥ 1 mm) in low voltage QRS complexes (maximal R or S wave is £ 6 mm) is abnormal in any lead
The BARCELONA algorithm reportedly attained the highest sensitivity and negative predictive values (compared to Sgarbossa & Smith), while maintaining high specificity
While the high sensitivity and specificity of the new Barcelona algorithm are promising, they still need external validation to see if the criteria perform as well after independent assessment
References:
Di Marco A, Rodriguez M, Cinca J, et al. New Electrocardiographic Algorithm for the Diagnosis of Acute Myocardial Infarction in Patients with Left Bundle Branch Block. J Am Heart Assoc. 2020;9(14):e015573. PMID: 32627643.
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. PMID: 22939607.
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? American Heart Journal. 2013;166(3):409–413. PMID: 24016487.
Pendell Meyers H, Limkakeng AT, 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. PMID: 26678648.
5. 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 2017;39(2):119–77. PMID: 28886621
Click the following link to learn more about current international criteria for emergent reperfusion in LBBB and Paced Rhythms
Click the following link to learn more about current international criteria for emergent reperfusion in LBBB and Paced Rhythms
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