Cardiology Department, Third Faculty of Medicine, Charles University Prague, University Hospital Kralovske Vinohrady, Srobarova 50, Prague 10, Czech Republic.
Eur Heart J. 2012 Jan;33(1):86-95. doi: 10.1093/eurheartj/ehr291. Epub 2011 Sep 1.
The current guidelines recommend reperfusion therapy in acute myocardial infarction (AMI) with ST-segment elevation or left bundle branch block (LBBB). Surprisingly, the right bundle branch block (RBBB) is not listed as an indication for reperfusion therapy. This study analysed patients with AMI presenting with RBBB [with or without left anterior hemiblock (LAH) or left posterior hemiblock (LPH)] and compared them with those presenting with LBBB or with other electrocardiographic (ECG) patterns. The aim was to describe angiographic patterns and primary angioplasty use in AMI patients with RBBB.
A cohort of 6742 patients with AMI admitted to eight participating hospitals was analysed. Baseline clinical characteristics, ECG patterns, coronary angiographic, and echocardiographic data were correlated with the reperfusion therapies used and with in-hospital outcomes. Right bundle branch block was present in 6.3% of AMI patients: 2.8% had RBBB alone, 3.2% had RBBB + LAH, and 0.3% had RBBB + LPH. TIMI flow 0 in the infarct-related artery was present in 51.7% of RBBB patients vs. 39.4% of LBBB patients (P = 0.023). Primary percutaneous coronary intervention (PCI) was performed in 80.1% of RBBB patients vs. 68.3% of LBBB patients (P< 0.001). In-hospital mortality of RBBB patients was similar to LBBB (14.3 vs. 13.1%, P = 0.661). Patients with new or presumably new blocks had the highest (LBBB 15.8% and RBBB 15.4%) incidence of cardiogenic shock from all ECG subgroups. Percutaneous coronary intervention was done more frequently (84.8%) in patients with new or presumably new RBBB when compared with other patients with blocks (old RBBB 66.0%, old LBBB 62.3%, new or presumably new LBBB 73.0%). In-hospital mortality was highest (18.8%) among patients presenting with new or presumably new RBBB, followed by new or presumably new LBBB (13.2%), old LBBB (10.1%), and old RBBB (6.4%). Among 35 patients with acute left main coronary artery occlusion, 26% presented with RBBB (mostly with LAH) on the admission ECG.
Acute myocardial infarction with RBBB is frequently caused by the complete occlusion of the infarct-related artery and is more frequently treated with primary PCI when compared with AMI + LBBB. In-hospital mortality of patients with AMI and RBBB is highest from all ECG presentations of AMI. Restoration of coronary flow by primary PCI may lead to resolution of the conduction delay on the discharge ECG. Right bundle branch block should strongly be considered for listing in future guidelines as a standard indication for reperfusion therapy, in the same way as LBBB.
目前的指南建议对 ST 段抬高或左束支传导阻滞（LBBB）的急性心肌梗死（AMI）进行再灌注治疗。令人惊讶的是，右束支传导阻滞（RBBB）并未被列为再灌注治疗的适应证。本研究分析了 AMI 合并 RBBB[伴或不伴左前半支阻滞（LAH）或左后半支阻滞（LPH）]患者，并将其与 LBBB 或其他心电图（ECG）模式的患者进行比较。目的是描述 AMI 合并 RBBB 患者的血管造影模式和直接经皮冠状动脉介入治疗（PCI）的应用。
对 8 家参与医院收治的 6742 例 AMI 患者进行了队列分析。将基线临床特征、ECG 模式、冠状动脉造影和超声心动图数据与使用的再灌注治疗方法以及院内结局相关联。AMI 患者中 RBBB 占 6.3%：单纯 RBBB 占 2.8%，RBBB+LAH 占 3.2%，RBBB+LPH 占 0.3%。梗死相关动脉 TIMI 血流 0 级在 RBBB 患者中占 51.7%，而在 LBBB 患者中占 39.4%（P=0.023）。直接 PCI 在 RBBB 患者中的使用率为 80.1%，而在 LBBB 患者中为 68.3%（P<0.001）。RBBB 患者的院内死亡率与 LBBB 相似（14.3% vs. 13.1%，P=0.661）。在所有 ECG 亚组中，新发或疑似新发阻滞患者的心源性休克发生率最高（LBBB 15.8%和 RBBB 15.4%）。与其他阻滞患者（陈旧性 RBBB 66.0%、陈旧性 LBBB 62.3%、新发或疑似新发 LBBB 73.0%）相比，新发或疑似新发 RBBB 患者更常接受直接 PCI（84.8%）。新发或疑似新发 RBBB 患者的院内死亡率最高（18.8%），其次是新发或疑似新发 LBBB（13.2%）、陈旧性 LBBB（10.1%）和陈旧性 RBBB（6.4%）。在 35 例急性左主干闭塞患者中，26%入院时 ECG 表现为 RBBB（主要为 LAH）。
RBBB 合并 AMI 常由梗死相关动脉完全闭塞引起，与 AMI+LBBB 相比，更常采用直接 PCI 治疗。在所有 AMI 的 ECG 表现中，RBBB 合并 AMI 患者的院内死亡率最高。直接 PCI 恢复冠状动脉血流可能导致出院时 ECG 上的传导延迟得到缓解。右束支传导阻滞应强烈考虑列入未来指南，作为与 LBBB 相同的再灌注治疗标准适应证。
