Diagnosis of acute myocardial infarction in the presence of left bundle branch block
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Diagnosis of acute myocardial infarction in the presence of left bundle branch block. / APACE, ADAPT and TRAPID-AMI Investigators.
In: HEART, Vol. 105, No. 20, 10.2019, p. 1559-1567.Research output: SCORING: Contribution to journal › SCORING: Journal article › Research › peer-review
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TY - JOUR
T1 - Diagnosis of acute myocardial infarction in the presence of left bundle branch block
AU - Nestelberger, Thomas
AU - Cullen, Louise
AU - Lindahl, Bertil
AU - Reichlin, Tobias
AU - Greenslade, Jaimi H
AU - Giannitsis, Evangelos
AU - Christ, Michael
AU - Morawiec, Beata
AU - Miro, Oscar
AU - Martín-Sánchez, Francisco Javier
AU - Wussler, Desiree Nadine
AU - Koechlin, Luca
AU - Twerenbold, Raphael
AU - Parsonage, William
AU - Boeddinghaus, Jasper
AU - Rubini Gimenez, Maria
AU - Puelacher, Christian
AU - Wildi, Karin
AU - Buerge, Tobias
AU - Badertscher, Patrick
AU - DuFaydeLavallaz, Jeanne
AU - Strebel, Ivo
AU - Croton, Lukas
AU - Bendig, Garnet
AU - Osswald, Stefan
AU - Pickering, John William
AU - Than, Martin
AU - Mueller, Christian
AU - APACE, ADAPT and TRAPID-AMI Investigators
N1 - © Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.
PY - 2019/10
Y1 - 2019/10
N2 - 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.
AB - 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.
KW - Algorithms
KW - Area Under Curve
KW - Biomarkers/analysis
KW - Bundle-Branch Block/diagnosis
KW - Clinical Decision Rules
KW - Diagnostic Errors/prevention & control
KW - Electrocardiography/methods
KW - Emergency Service, Hospital/statistics & numerical data
KW - Female
KW - Humans
KW - Male
KW - Middle Aged
KW - Myocardial Infarction/blood
KW - Prospective Studies
KW - Time-to-Treatment
KW - Troponin I/analysis
U2 - 10.1136/heartjnl-2018-314673
DO - 10.1136/heartjnl-2018-314673
M3 - SCORING: Journal article
C2 - 31142594
VL - 105
SP - 1559
EP - 1567
JO - HEART
JF - HEART
SN - 1355-6037
IS - 20
ER -
