Jump to comment:

• Simpler thrombolysis decisions in patients with LBBB
  Jonathan R Benger
  Published on: 29 April 2016
• Revision for flow chart - figure 3
  Rob Z Torok
  Published on: 29 April 2016
• LBBB with MI
  Mark T Lown
  Published on: 29 April 2016

• Published on: 29 April 2016

  Simpler thrombolysis decisions in patients with LBBB

  • Jonathan R Benger, Consultant in Emergency Medicine

  Dear Editor,

  I read the article by Reuben and Mann “simplifying thrombolysis decisions in patients with left bundle branch block” with considerable interest.[1] This is a useful way of presenting the Sgarbossa criteria, which have high specificity for acute myocardial infarction (AMI). Unfortunately, however, these criteria are far too insensitive to exclude MI, being present in only 20% of patients with left bun...

  Show More

  Dear Editor,

  I read the article by Reuben and Mann “simplifying thrombolysis decisions in patients with left bundle branch block” with considerable interest.[1] This is a useful way of presenting the Sgarbossa criteria, which have high specificity for acute myocardial infarction (AMI). Unfortunately, however, these criteria are far too insensitive to exclude MI, being present in only 20% of patients with left bundle branch block (LBBB) and confirmed AMI.[2,3] It is therefore important that less experienced practitioners do not conclude that thrombolysis should be withheld if these ECG features are absent.

  In fact, the simplest thrombolysis decision is that all patients with a history strongly suggestive of AMI and LBBB should receive thrombolysis, unless significant contraindications exist. Even the well-rehearsed medical myths relating to the age of the LBBB are of minimal relevance, as described in an elegant editorial referenced by the authors.[4] Patients with left bundle branch block have the most to gain from thrombolysis,[5] but are still failing to receive this highly effective therapy in too many cases.

  In summary, therefore, where Sgarbossa criteria are seen on the ECG AMI is highly likely. However even in the absence of these features patients with a convincing history of AMI and LBBB should still receive thrombolysis, unless there are compelling reasons against.

  Yours sincerely,

  Jonathan Benger

  References

  1. Reuben AD, Mann CJ. Simplifying thrombolysis decisions in patients with left bundle branch block. Emerg Med J 2005;22:617-20.

  2. Kontos MC, McQueen RH, Jesse RL, et al. Can myocardial infarction be rapidly identified in emergency department patients who have left bundle branch block? Ann Emerg Med 2001;37:431-8.

  3. Li SF, Walden PL, Marcilla O, et al. Electrocardiographic diagnosis of myocardial infarction in patients with left bundle branch block. Ann Emerg Med 2000;36:561-5.

  4. Gallagher EJ. Which patients with suspected myocardial ischemia and left bundle branch block should receive thrombolytic agents? Ann Emerg Med 2001;37:439-44.

  5. Newby KH, Pisano E, Krikoff MW, et al. Incidence and clinical relevance of the occurrence of bundle-branch block in patients treated with thrombolytic therapy. Circulation 1999;94:2424-8.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 29 April 2016

  Revision for flow chart - figure 3

  • Rob Z Torok, ED SpR

  Dear Editor,

  I read this article by A Reuben and C Mann with interest and congratulate them on their approach and success with this work. They have succinctly clarified a decision tree which previously took some mental effort to navigate.

  The heading for the third box in the middle of figure 3 should read ST depression > 1mm rather than as stated elevation.

  While this undoubtedly represents a t...

  Show More

  Dear Editor,

  I read this article by A Reuben and C Mann with interest and congratulate them on their approach and success with this work. They have succinctly clarified a decision tree which previously took some mental effort to navigate.

  The heading for the third box in the middle of figure 3 should read ST depression > 1mm rather than as stated elevation.

  While this undoubtedly represents a typing error and is clear both from Sgarbossas own criteria and from the rest of the article, I felt it worth highlighting in case readers considered the flow chart in isolation.

  Many thanks

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 29 April 2016

  LBBB with MI

  • Mark T Lown, Medical Student

  Dear Editor,

  I don't think the sgarbossa criteria are that useful. In the example ECG, the 2 strikingly obvious criteria that would indicate acute MI are the hyperacute T waves laterally (the absolute height of the T wave being greater than that of the the QRS) and the high ST to T ratio laterally. It is only Anterior MIs that are difficult to diagnose in the presence of LBBB. The presence of hyperacute Ts is s...

  Show More

  Dear Editor,

  I don't think the sgarbossa criteria are that useful. In the example ECG, the 2 strikingly obvious criteria that would indicate acute MI are the hyperacute T waves laterally (the absolute height of the T wave being greater than that of the the QRS) and the high ST to T ratio laterally. It is only Anterior MIs that are difficult to diagnose in the presence of LBBB. The presence of hyperacute Ts is specific and sensitive. Pure elevation thresholds are not. The only merit of the sgarbossa criteria is that it'll pick up lateral elevation where there is usually depression and T wave inversion without MI

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top