Editor,—We congratulate Edhouse et al¹ on their attempt to try and produce some clarity in the murky waters of diagnosing and treating patients with acute myocardial infarction (AMI), who present with left bundle branch block (LBBB). Unfortunately, we feel that the study has some limitations that could provide for some confusing “take home” messages. There are four points to consider:

1. The original article, Sgarbossa et al,² was published with an editorial and generated a number of subsequent letters,^{3, 4} which were rightly critical of the cohort chosen and the subsequent extrapolation of results. These views are not adequately reviewed and the “spin” in the discussion by Edhouse et al in our opinion, is overly supportive of Sgarbossa's criteria.

2. The prevalence of AMI in Edhouse's article is 0.5 and is unusually high for patients presenting to accident and emergency with cardiac sounding chest pain. The method section seems to suggest that these patients were derived from a database of patients eligible for thrombolysis, which would not be an appropriate study population. This is an important point that requires clarification by the authors.

3. In the conclusion, the first sentence rightly points out the need for thrombolysing all patients with LBBB and persisting cardiac pain. The last sentence …