Di Marco Andrea, Anguera Ignasi, Rodríguez Marcos, Sionis Alessandro, Bayes-Genis Antoni, Rodríguez Jany, Ariza-Solé Albert, Sánchez-Salado José Carlos, Díaz-Nuila Mario, Masotti Mónica, Villuendas Roger, Dallaglio Paolo, Gómez-Hospital Joan Antoni, Cequier Ángel
Área del Corazón, Servicio de Cardiología, Hospital Universitario de Bellvitge, Barcelona, Spain.
Área del Corazón, Servicio de Cardiología, Hospital Universitario de Bellvitge, Barcelona, Spain.
Rev Esp Cardiol (Engl Ed). 2017 Jul;70(7):559-566. doi: 10.1016/j.rec.2016.11.017. Epub 2016 Dec 24.
Recently, a new electrocardiography algorithm has shown promising results for the the diagnosis of acute myocardial infarction in the presence of left bundle branch block (LBBB). We aimed to assess these new electrocardiography rules in a cohort of patients referred for primary percutaneous coronary intervention (pPCI).
Retrospective observational cohort study that included all patients with suspected myocardial infarction and LBBB on the presenting electrocardiogram, referred for pPCI to 4 tertiary hospitals in Barcelona, Spain.
A total of 145 patients were included. Fifty four (37%) had an ST-segment elevation myocardial infarction (STEMI) equivalent. Among patients with STEMI, 25 (46%) presented in Killip class III or IV, and in-hospital mortality was 15%. Smith I and II rules performed better than Sgarbossa algorithms and showed good specificity (90% and 97%, respectively) but their sensitivity was 67% and 54%, respectively. In a strategy guided by Smith I or Smith II rules, 18 (33%) or 25 (46%) patients with STEMI would have not received a pPCI, respectively. Moreover, the severity and prognosis of STEMI patients was similar regardless of the positivity of Smith rules. Cardiac biomarkers were positive in 54% of non-STEMI patients, limiting their usefulness for initial diagnostic screening.
Diagnosis of STEMI in the presence of LBBB remains a challenge. Smith rules can be useful but are limited by suboptimal sensitivity. The search for new electrocardiography algorithms should be encouraged to avoid unnecessary aggressive treatments in the majority of patients, while providing timely reperfusion to a high-risk subgroup of patients.
最近，一种新的心电图算法在诊断存在左束支传导阻滞（LBBB）的急性心肌梗死方面显示出了有前景的结果。我们旨在对一组接受直接经皮冠状动脉介入治疗（pPCI）的患者评估这些新的心电图规则。
回顾性观察队列研究，纳入了所有在初始心电图上有疑似心肌梗死和LBBB且被转诊至西班牙巴塞罗那4家三级医院接受pPCI的患者。
共纳入145例患者。54例（37%）有ST段抬高型心肌梗死（STEMI）等效情况。在STEMI患者中，25例（46%）表现为Killip III或IV级，住院死亡率为15%。Smith I和II规则比Sgarbossa算法表现更好，且显示出良好的特异性（分别为90%和97%），但其敏感性分别为67%和54%。在由Smith I或Smith II规则指导的策略中，分别有18例（33%）或25例（46%）STEMI患者不会接受pPCI。此外，无论Smith规则是否阳性，STEMI患者的严重程度和预后相似。54%的非STEMI患者心脏生物标志物呈阳性，限制了其在初始诊断筛查中的作用。
在存在LBBB的情况下诊断STEMI仍然是一项挑战。Smith规则可能有用，但受敏感性欠佳的限制。应鼓励寻找新的心电图算法，以避免对大多数患者进行不必要的积极治疗，同时为高危亚组患者提供及时的再灌注治疗。
