Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.
Department of Cardiology, Zealand University Hospital, Roskilde, Denmark; Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen, Denmark.
Am J Med. 2024 Aug;137(8):770-775.e1. doi: 10.1016/j.amjmed.2024.04.021. Epub 2024 Apr 24.
While left bundle branch block (LBBB) is a well-known risk feature in patients with acute myocardial infarction, and a rapid invasive management is recommended, data supporting this strategy for patients with right bundle branch block (RBBB) is less robust.
In total, 2139 patients with suspected ST-elevation myocardial infarction (STEMI) were triaged to acute coronary angiography based on a prehospital 12-lead electrocardiogram (ECG). Sensitivity and specificity for STEMI-ECG criteria were compared in RBBB and non-BBB patients. Adjusted hazard ratios for 1-year overall mortality were computed.
STEMI was adjudicated in 1832/2139 (85.6%) of all patients and in 102/117 (87.2%) of RBBB patients. ST-segment deviation followed typical ST-T patterns in most RBBB patients. Of 17 RBBB patients without significant ST changes, STEMI was adjudicated in 14 (82%). Diagnostic accuracy of STEMI criteria was comparable in RBBB and non-RBBB patients for inferior (sensitivity: 51.1% vs 59.1%, P = .14; specificity: 66.7% vs 52.1%, P = .33) and anterior STEMI (sensitivity: 35.2% vs 36.6%, P = .80; specificity: 58.3% vs 49.5%, P = .55). Diagnostic performance was lower for lateral STEMI in RBBB patients (sensitivity: 14.8% vs 4.4%, P = .001; specificity: 75.0% vs 98.4%, P < .001). Patients with RBBB had higher 1-year mortality compared with non-BBB patients (hazard ratio 2.3%; 95% confidence interval, 1.25-4.21.
ECG criteria used for detection of STEMI showed comparable diagnostic accuracy in RBBB and non-BBB patients. However, STEMI was frequently present in RBBB patients not fulfilling diagnostic ECG criteria. RBBB patients showed poorer outcome after 1 year. Consequently, the presence of RBBB in suspected STEMI cases signifies a high-risk feature, aligning with established guidelines.
左束支传导阻滞（LBBB）是急性心肌梗死患者的一个众所周知的危险特征，推荐进行快速有创性管理，然而对于右束支传导阻滞（RBBB）患者，支持这种策略的数据则不那么充分。
共有 2139 例疑似 ST 段抬高型心肌梗死（STEMI）患者根据院前 12 导联心电图（ECG）进行急性冠状动脉造影。比较了 RBBB 和非 RBBB 患者中 STEMI-ECG 标准的敏感性和特异性。计算了 1 年总死亡率的校正风险比。
所有患者中 1832/2139（85.6%）和 102/117（87.2%）患者被诊断为 STEMI。大多数 RBBB 患者的 ST 段偏移遵循典型的 ST-T 模式。在 17 例无明显 ST 改变的 RBBB 患者中，有 14 例（82%）被诊断为 STEMI。STEMI 标准的诊断准确性在 RBBB 和非 RBBB 患者中相似，下壁 STEMI 的敏感性分别为 51.1%和 59.1%（P =.14），特异性分别为 66.7%和 52.1%（P =.33）；前壁 STEMI 的敏感性分别为 35.2%和 36.6%（P =.80），特异性分别为 58.3%和 49.5%（P =.55）。在 RBBB 患者中， lateral STEMI 的诊断性能较低，敏感性分别为 14.8%和 4.4%（P =.001），特异性分别为 75.0%和 98.4%（P <.001）。与非 RBBB 患者相比，RBBB 患者 1 年死亡率更高（风险比 2.3%；95%置信区间，1.25-4.21）。
用于检测 STEMI 的 ECG 标准在 RBBB 和非 RBBB 患者中具有相似的诊断准确性。然而，不符合诊断 ECG 标准的 RBBB 患者中，STEMI 经常存在。RBBB 患者在 1 年后的预后较差。因此，怀疑为 STEMI 的病例中存在 RBBB 表示高危特征，与既定指南一致。
