Left bundle branch block in acute myocardial ischemia/infarction (AMI) and acute coronary syndromes (ACS)
On the contrary to right bundle branch block, left bundle branch block is always a pathological finding which affects cardiovascular and total mortality. Left bundle branch block is more common in individuals with structural and ischemic heart disease.
Assessment of ischemia on the ECG is difficult in presence of left bundle branch block. This is because left bundle branch block causes substantial changes in left ventricular de- and repolarization. Left bundle branch block always causes secondary ST-T changes which may imitate and/or mask ischemia. The imitation of ischemia manifests as ST segment elevations in lead V1–V2 and ST segment depressions in lead V5, V6, I and aVL. Clinicians frequently confuse these elevations and depressions with those caused by STE-ACS/STEMI. Indeed, several studies have shown that the majority of patients inappropriately referred to the catheterization laboratory (for PCI) with a suspicion of STE-ACS/STEMI actually have left bundle branch block. Masking of ischemia occurs simply because the ST-T changes caused by the bundle branch block are stronger than the ST-T changes caused by ischemia, and therefore the ischemia will not come to expression (there are exceptions to this rule, as discussed below).
Implications of left bundle branch block in myocardial ischemia/infarction
A summary of the issues that arise when facing a patient with left bundle branch block and symptoms of ischemia follows:
- Imitation: left bundle branch block causes secondary ST-T changes, with ST-segment elevations in V1–V2 and ST-segment depressions and T-wave inversions in V5, V6, aVL and I. QS complex may be seen in V1–V2.
- Masking: Left bundle branch block may mask actual ischemic ST-T changes.
- Danger: A new left bundle branch block in patients with chest discomfort implies a relatively high probability of acute coronary artery occlusion. These patients should be managed as patients with STEMI/STE-ACS. If there are no previous ECG recordings available, one must presume that the left bundle branch block is new.
Management of left bundle branch block (LBBB) in patients with acute coronary syndromes (ACS)
As discussed earlier, patients with chest discomfort and new or presumed new left bundle branch block must be referred immediately to the catheterization laboratory in order to undergo angiography. This is because early studies (dating back to the 1990s) showed that patients with chest discomfort and a new (or presumed new) left bundle branch block who were referred immediately to angiography (PCI) had better survival than comparable patients who did not undergo angiography. A significant proportion of these patients had an acute coronary artery occlusion and it was suggested that the occlusion had caused the left bundle branch block. Ever since, guidelines have recommended that patients with chest discomfort and new or presumably new left bundle branch block should be managed as patients with STE-ACS/STEMI (i.e they should immediately undergo angiography). This will unfortunately lead to many unnecessary referrals because only a minority (ranging between 5% to 20%) of these patients actually have an acute occlusion. The many false positives are due to the following:
- A significant proportion of the left bundle branch blocks are not new, but simply new to the health care system (e.g lack of previous ECG recordings).
- Even if the left bundle branch block is new, the occlusion may not be total, in which case PCI does not confer any survival benefit.
Sgarbossa’s ECG criteria for detecting ischemia in the presence of left bundle branch block (LBBB)
For obvious reasons, researchers have worked intensely on trying to sort out ECG changes that indicate ischemia in the presence of left bundle branch block. The greatest progress was made in 1996 by Elena Sgarbossa and colleagues (using data from the GUSTO-I study). They developed a set of criteria which are easy to use and have been validated in several studies. These criteria, referred to as Sgarbossa’s criteria, may determine whether there is acute ischemia on ECGs with left bundle branch block. The Sgarbossa criteria consist of three simple criteria and may be applied to all left bundle branch blocks, regardless of time of onset.
Each criteria gives 2 to 5 points. Studies show that a cut-off of ≥3 points yields a sensitivity of 20–36% and specificity of 90–98%. The following table presents Sgarbossa’s criteria.
Left bundle branch block (LBBB), left ventricular hypertrophy (LVH) and pacemaker rhythm excludes infarction criteria
European and North American guidelines assert that ECG criteria of ischemia/infarction may not be applied if the ECG shows left bundle branch block, left ventricular hypertrophy or ventricular pacemaker rhythm. This is simply because these conditions alter the ECG waveforms – both QRS and ST-T – markedly and may both mask and imitate ischemia. One is, however, free to attempt to interpret ischemia on ECGs showing these conditions. This procedure has been discussed above for left bundle branch block. Additionally, some general advice may be given (these overlap somewhat with the Sgarbossa criteria and may be applied to all three of these situations).
- Always control if the ECG waveforms differs from earlier ECG recordings. If there are differences in the ST-T segment, it might be due to ischemia.
- Always control if the ECG waveforms are consistent with the condition. For example, it is normal to display T-wave inversions in V5, V6, aVL and I in left bundle branch block; absence of such T-wave inversions suggest ischemia!
- Search for pseudonormalization of T-waves.