Division of Cardiology, University of Texas Medical Branch, Galveston, TX; Department of Cardiology, McFarland Clinic, Ames, IA.
Am Heart J. 2013 Sep;166(3):409-13. doi: 10.1016/j.ahj.2013.03.032. Epub 2013 Aug 6.
Prompt and accurate identification of ST-elevation myocardial infarction (STEMI) in the presence of left bundle-branch block (LBBB) remains difficult. The 2004 STEMI guideline recommended emergent reperfusion therapy to patients with suspected ischemia and new or presumably new LBBB. These recommendations have led to frequent false catheterization laboratory activation and inappropriate fibrinolytic therapy because most patients with suspected ischemia and new or presumably new LBBB do not have acute coronary artery occlusion on angiography. The new 2013 STEMI guideline makes a drastic change by removing previous recommendations. Therefore, patients with suspected ischemia and new or presumably new LBBB would no longer be treated as STEMI equivalent. The new guideline fails to recognize that some patients with suspected ischemia and LBBB do have STEMI, and denying reperfusion therapy could be fatal. The Sgarbossa electrocardiography criteria are the most validated tool to aid in the diagnosis of STEMI in the presence of LBBB. A Sgarbossa score of ≥3 has a superb specificity (98%) and positive predictive value for acute myocardial infarction and angiography-confirmed acute coronary occlusion. Thus, we propose a diagnosis and triage algorithm incorporating the Sgarbossa criteria to quickly and accurately identify, among patients presenting with chest pain and new or presumably new LBBB, those with acute coronary artery occlusion. This is a high-risk population in which reperfusion therapy would be denied by the 2013 STEMI guideline. Our algorithm will also significantly reduce false catheterization laboratory activation and inappropriate fibrinolytic therapy, the inevitable consequence of the 2004 STEMI guideline.
在存在左束支传导阻滞（LBBB）的情况下，准确快速地识别 ST 段抬高型心肌梗死（STEMI）仍然具有挑战性。2004 年 STEMI 指南建议对疑似缺血且新发或疑似新发 LBBB 的患者进行紧急再灌注治疗。这些建议导致经常错误地激活导管实验室并进行不适当的溶栓治疗，因为大多数疑似缺血且新发或疑似新发 LBBB 的患者在血管造影上并没有急性冠状动脉闭塞。新的 2013 年 STEMI 指南做出了重大改变，删除了之前的建议。因此，疑似缺血且新发或疑似新发 LBBB 的患者不再被视为 STEMI 等效患者。新指南没有认识到一些疑似缺血且存在 LBBB 的患者确实患有 STEMI，拒绝再灌注治疗可能是致命的。Sgarbossa 心电图标准是辅助诊断 LBBB 存在时 STEMI 的最有效工具。Sgarbossa 评分≥3 时，对急性心肌梗死和经血管造影证实的急性冠状动脉闭塞具有极高的特异性（98%）和阳性预测值。因此，我们提出了一种诊断和分诊算法，该算法结合了 Sgarbossa 标准，可以快速准确地识别出胸痛且新发或疑似新发 LBBB 的患者中存在急性冠状动脉闭塞的患者。这是一个高风险人群，如果按照 2013 年 STEMI 指南，他们将被拒绝再灌注治疗。我们的算法还将显著减少错误的导管实验室激活和不适当的溶栓治疗，这是 2004 年 STEMI 指南的必然结果。
