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Diagnosis of Myocardial Infarction in a Patient with Left Bundle Branch Block and Negative Sgarbossa Criteria

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Diagnosis of Myocardial Infarction in a Patient with Left Bundle Branch Block and Negative Sgarbossa Criteria CASE REPORT Diagnosis of Myocardial Infarction in a Patient With Left Bundle Branch Block and Negative Sgarbossa Criteria Bryan Beaty, OMS III; David Park, DO From the Rocky Vista Left bundle branch block complicates electrocardiogram interpretation of University College of acute myocardial infarction (MI) because ST segment elevations, commonly Osteopathic Medicine Southern Utah Campus in used as evidence of MIs, are largely hidden by the repolarization vector. To Ivins, Utah. better diagnose acute MI in cases of left bundle branch block, modified Financial Disclosures: Sgarbossa criteria can be used as a clinical tool to help diagnose or exclude None reported. MI with high specificity and sensitivity. However, while clinical tools are often Support: None reported. helpful, a clinician cannot solely rely on clinical decision-making algorithms. Address correspondence to We describe the case of an 84-year-old man experiencing acute cardiopul- David Park, DO, 255 E Center monary symptoms who was negative for modified Sgarbossa criteria, but St, Ivins, UT 84738-6790. later had a confirmed diagnosis of MI on transfer to a cardiac center. This Email: [email protected] case illustrates the necessity of good clinical judgment and a high index of Submitted suspicion for atypical presentation alongside any diagnostic algorithm. October 25, 2019; accepted J Am Osteopath Assoc. 2020;120(10):655-659. Published online August 4, 2020. November 19, 2019. doi:10.7556/jaoa.2020.107 Keywords: myocardial infarction, Sgarbossa criteria T elevations on an electrocardiogram (ECG) are difficult to assess in patients with left bundle branch block (LBBB), complicating decision making for physi- S cians when acute myocardial infarction (MI) is in the differential diagnosis. Studies suggest the prevalence of LBBB is up to 1.4% in the general population.1-4 Adults with past myocardial injury may develop LBBB due to ischemic or fibrotic damage to the left bundle branch fibers of the His-Purkinje system.5 ECG changes that meet criteria for LBBB include QRS duration of greater than 120 ms, dominant S wave in V1, broad monophasic R wave in lateral leads (I, aVL, V5-V6), absence of Q waves in lateral leads (I, V5-V6), and prolonged R wave peak time greater than 60ms in left pre- cordial leads (V5-6; Figure 1).6 Damage to the left bundle branch fibers leads to altered pathways for ventricular depolarization and repolarization. This change in the cardiac electrical pathway will affect the vector of the repolarization pattern, such that ST-T wave vectors on ECG will be opposite to the QRS vector. This often hides ST segment changes in the QRS complex. ECG evidence of ST depression, ST elevation, or T wave inversion are indicators of ischemic injury in clinical settings. The Sgarbossa criteria were conceived in 1996 and provided a means to more accurately diagnose an acute MI in patients with a LBBB using a 10-point scoring system.7 A score greater than or equal to 3 was shown to have a summary sensitivity of 20% and specificity of 98% for diagnosis of acute MI in patients with a LBBB The Journal of the American Osteopathic Association October 2020 | Vol 120 | No. 10 655 CASE REPORT 1. QRS duration of > 120 ms 2. Dominant S wave in V1 3. Broad monophasic R wave in lateral leads (I, aVL, V5-V6) 4. Absence of Q waves in lateral leads (I, V5-V6) 5. Prolonged R wave peak time > 60 ms in left precordial leads (V5-V6) Figure 1. Electrocardiogram criteria for left bundle branch block.6 according to a 2008 meta-analysis of 11 studies with Report of Case 2,100 patients.8 The Sgarbossa criteria was later An 84-year-old man presented to the emergency depart- revised 2012, with the modified criteria demonstrating ment (ED) of a small community hospital with short- asignificantly higher sensitivity of 91% (from 20%) ness of breath and diaphoresis. Approximately 2 weeks and a slightly lower specificity of 90% (from 98%).9 prior, the patient presented to the same ED and was The modified Sgarbossa criteria include 3 measures, diagnosed with clostridium difficile colitis. He was hos- the presence of any 1 of which highly suggests pitalized for 2 days and treated with antibiotics and an acute MI: (1) ST elevation of 1 mm or more intravenous hydration, then transferred to a skilled concordant as the QRS complex in any lead, (2) ST nursing facility for continued antibiotics and acute depression of 1 mm or more in any of leads V1-V3, rehabilitation. He was discharged home from the or (3) an ST/S ratio of less than −0.25 (Figure 2).9 skilled nursing facility 5 days later. The patient was The absence of all 3 criteria highly suggests no acute home for 1 week when he noticed mild shortness of MI. breath on exertion, which lasted for 3 days until it sud- In this case report, we present an 84-year-old denly developed into severe difficulty breathing 2 hours man with a history of LBBB on ECG and MI before he arrived in the ED by ambulance. The patient despite not meeting any modified Sgarbossa criteria. denied any chest pain, palpitations, cough, fever, or In discussing this case, we hope to show that the chills. His history was otherwise unremarkable. The modified Sgarbossa criteria is a good clinical tool patient also denied any history of previous MI, congest- to help diagnose MI in patients with LBBB, but also ive heart failure, or other known cardiac disease. There to demonstrate that the use of any single clinical was no history of chronic obstructive pulmonary tool is not foolproof and should not replace clinical disease or other lung disease. The patient’s other past judgement. medical history included diabetes, gastroesophageal If any of the below criteria are met, patient should be managed for a STEMI: • ST elevation of 1 mm or more concordant as the QRS complex in any lead • ST depression of 1 mm or more in any of leads V1-V3 • ST/S ratio less than −0.25. All measurements made from the PR segment, and ST segment is measured from the J-point. Figure 2. Modified Sgarbossa criteria for diagnosing acute myocardial infarction in patients with left bundle branch block.9 Abbreviation: STEMI, ST-elevation myocardial infarction. 656 The Journal of the American Osteopathic Association October 2020 | Vol 120 | No. 10 CASE REPORT Figure 3. A 12-lead electrocardiogram (ECG) from an 84-year-old man who presented to the emergency department with a primary complaint of shortness of breath. Results showed sinus tachycardia at 112 beats per minute and left bundle branch block. reflux disease, hyperlipidemia, hypertension, and the (>120 ms), and there was a dominant S wave in V1, a recent clostridium difficile infection. His surgical broad monophasic R wave in lateral leads (I, aVL, history was notable for bilateral knee operation and a V5-V6), absence of Q waves in lateral leads (I, right hip replacement. Home medications included lisi- V5-V6),andaprolongedRwavepeaktime(>60ms) nopril, finasteride, lovastatin, lantus, nifedipine, ome- in left precordial leads (V5-6), consistent with an prazole, and tamsulosin. LBBB diagnosis.6 (Figure 1) Evaluating according to On arrival to the ED, the patient was afebrile with a the modified Sgarbossa criteria, there were no ST blood pressure of 158/75 mmHg, pulse of 113 beats per segment elevations in the same direction as the QRS minute, 22 respirations per minute, and pulse oximetry vectors in leads V1, V2, V3, and V4 (negative criter- of 88% on nonrebreather oxygen mask. On physical ion). There were no ST segment depressions in any examination, the patient exhibited severe respiratory dis- leads (negative criterion). The ST/S ratio was not less tress with accessory muscle use, bibasilar rales, scattered than −0.25 in any leads (negative criterion). In short, rhonchi, and scattered wheezes. He was tachycardic with this patient did not meet the modified Sgarbossa criteria a regular rhythm and a 1/6 systolic murmur; 3+ pitting for an MI. Before laboratory test results were available, ankle edema was also noted. No jugular venous disten- the patient was placed on bilevel positive airway pres- sion or pulse deficits were appreciated. The patient’s sure after failure to raise oxygen saturation with nonreb- abdomen was moderately distended, but soft and non- reather mask. Furosemide was given intravenously for tender. There was no tenderness of his lower extremities. suspected acute congestive heart failure and fluid over- A 12 lead ECG showed sinus tachycardia at 112 load. A chest radiography showed central vascular con- beats per minute (Figure 3). Axis and PR intervals gestion and bilateral small pleural effusions (Figure 4). were normal. The QRS interval was prolonged Laboratory test results showed a white blood cell count The Journal of the American Osteopathic Association October 2020 | Vol 120 | No. 10 657 CASE REPORT of 17,700 K/cmm (reference range,10 4000-11,000 more than 430,000 patients with confirmed acute MI, K/cmm) with a high percent neutrophils at 86.4% one-third had no chest pain on presentation to the hos- (reference range,10 50-70%). Reflex lactic acid was 2.3 pital. Patients who were older, were women, or had dia- mmol/L (reference range,10 0.7-2.1 mmol/L). Blood betes most frequently presented without chest pain, and urea nitrogen was 43 mg/dL (reference range,10 8-20 patients with MI without chest pain had a 23.3% mg/dL) and serum creatinine was 1.67 mg/dL (reference in-hospital mortality rate compared with 9.3% among range,10 0.70-1.30 mg/dL) with estimated glomerular fil- patients with MI chest pain.11 Another study12 found tration rate of 39 mL/min (reference range,10 90-140 mL/ that the rate of missed acute MI was 2.1% and varied min).
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